Healthcare Provider Details

I. General information

NPI: 1710924428
Provider Name (Legal Business Name): COMMUNITY MEMORIAL HOSPITAL ASSOCIATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/01/2006
Last Update Date: 09/05/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

512 SKYLINE BLVD
CLOQUET MN
55720-3787
US

IV. Provider business mailing address

512 SKYLINE BLVD
CLOQUET MN
55720-3787
US

V. Phone/Fax

Practice location:
  • Phone: 218-879-4641
  • Fax: 218-879-3237
Mailing address:
  • Phone: 218-879-4641
  • Fax: 218-879-3237

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License NumberMN331132
License Number StateMN

VIII. Authorized Official

Name: MR. RICHARD L. BREUER
Title or Position: CEO/ADMINISTRATOR
Credential:
Phone: 218-878-7621