Basic Information
Provider Information | |||||||||
NPI: | 1740302371 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | TRINITY KENMARE HOSPITAL | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | TRINITY KENMARE SWING BED | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 5020 | ||||||||
Address2: |   | ||||||||
City: | MINOT | ||||||||
State: | ND | ||||||||
PostalCode: | 587025020 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7013854296 | ||||||||
FaxNumber: | 7013854282 | ||||||||
Practice Location | |||||||||
Address1: | 317 1ST AVE NW | ||||||||
Address2: |   | ||||||||
City: | KENMARE | ||||||||
State: | ND | ||||||||
PostalCode: | 58746 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7013854296 | ||||||||
FaxNumber: | 7018575117 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/04/2007 | ||||||||
LastUpdateDate: | 11/30/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | KUTCH | ||||||||
AuthorizedOfficialFirstName: | JOHN | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CEO | ||||||||
AuthorizedOfficialTelephone: | 7018575000 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | TRINITY KENMARE HOSPITAL | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 11/30/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282NC0060X | 5028P | ND | Y |   | Hospitals | General Acute Care Hospital | Critical Access |
ID Information
ID | Type | State | Issuer | Description | 35Z305 | 01 | ND | MEDICARE | OTHER | 1459061 | 05 | ND |   | MEDICAID |