Basic Information
| Provider Information | |||||||||
| NPI: | 1821647413 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | KREMMLING MEMORIAL HOSPITAL DISTRICT | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | MIDDLE PARK MEDICAL CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 399 | ||||||||
| Address2: | |||||||||
| City: | KREMMLING | ||||||||
| State: | CO | ||||||||
| PostalCode: | 804590399 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9707243171 | ||||||||
| FaxNumber: | 9707249606 | ||||||||
| Practice Location | |||||||||
| Address1: | 45 COUNTY ROAD 804 | ||||||||
| Address2: | |||||||||
| City: | FRASER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 804420000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9707243171 | ||||||||
| FaxNumber: | 9707249606 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/06/2019 | ||||||||
| LastUpdateDate: | 09/26/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HORNER | ||||||||
| AuthorizedOfficialFirstName: | MIKEALENA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 9707243171 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | KREMMLING MEMORIAL HOSPITAL DISTRICT | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 09/26/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2000X | Y | Ambulatory Health Care Facilities | Clinic/Center | Physical Therapy |
ID Information
| ID | Type | State | Issuer | Description | 9000141155 | 05 | CO | MEDICAID |