Healthcare Provider Details

I. General information

NPI: 1205244944
Provider Name (Legal Business Name): PEMBINA COUNTY MEMORIAL HOSPITAL ASSOCIATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/25/2014
Last Update Date: 07/25/2022
Certification Date: 07/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 MOUNTAIN ST E
CAVALIER ND
58220-4015
US

IV. Provider business mailing address

301 MOUNTAIN ST E PO BOX 380
CAVALIER ND
58220-4015
US

V. Phone/Fax

Practice location:
  • Phone: 701-265-6307
  • Fax: 701-265-6373
Mailing address:
  • Phone: 701-265-6307
  • Fax: 701-265-6373

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPAC0563
License Number StateND

VIII. Authorized Official

Name: MS. LISA R LETEXIER
Title or Position: CEO
Credential: CEO
Phone: 701-265-6228