=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124456629
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KREMMLING MEMORIAL HOSPITAL DISTRICT
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/18/2013
-----------------------------------------------------
Last Update Date | 03/18/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1000 GRANBY PARK DRIVE SOUTH
-----------------------------------------------------
City | GRANBY
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80446-1169
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 970-724-3442
-----------------------------------------------------
Fax | 970-724-9606
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 399
-----------------------------------------------------
City | KREMMLING
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80459-0399
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 970-724-3442
-----------------------------------------------------
Fax | 970-724-9606
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | JASON MARSHALL CLECKLER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 970-208-2907
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QC0050X
-----------------------------------------------------
Taxonomy Name | Critical Access Hospital Clinic/Center
-----------------------------------------------------
License Number | 010804
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QM1300X
-----------------------------------------------------
Taxonomy Name | Multi-Specialty Clinic/Center
-----------------------------------------------------
License Number | 00.0000156
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 261QM1300X
-----------------------------------------------------
Taxonomy Name | Multi-Specialty Clinic/Center
-----------------------------------------------------
License Number | 0000156
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 261QR1300X
-----------------------------------------------------
Taxonomy Name | Rural Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------