Provider Demographics
NPI:1124456629
Name:KREMMLING MEMORIAL HOSPITAL DISTRICT
Entity type:Organization
Organization Name:KREMMLING MEMORIAL HOSPITAL DISTRICT
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JASON
Authorized Official - Middle Name:MARSHALL
Authorized Official - Last Name:CLECKLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:970-208-2907
Mailing Address - Street 1:PO BOX 399
Mailing Address - Street 2:
Mailing Address - City:KREMMLING
Mailing Address - State:CO
Mailing Address - Zip Code:80459-0399
Mailing Address - Country:US
Mailing Address - Phone:970-724-3442
Mailing Address - Fax:970-724-9606
Practice Address - Street 1:1000 GRANBY PARK DRIVE SOUTH
Practice Address - Street 2:
Practice Address - City:GRANBY
Practice Address - State:CO
Practice Address - Zip Code:80446-1169
Practice Address - Country:US
Practice Address - Phone:970-724-3442
Practice Address - Fax:970-724-9606
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:KREMMLING MEMORIAL HOSPITAL DISTRICT
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-10-18
Last Update Date:2024-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO010804261QC0050X
CO00.0000156261QM1300X
CO0000156261QM1300X
CO261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
No261QC0050XAmbulatory Health Care FacilitiesClinic/CenterCritical Access Hospital
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO9000226213Medicaid
CO061318Medicare PIN