NPIMap

Organization Active NPI

Pembina County Memorial Hospital Association

  • Medicare Defined Swing Bed Hospital Unit
  • Cavalier, ND
National Provider Identifier
1063634210
Registry record updated Jul 25, 2022
On this page

Key facts

NPPES NPI Registry
Primary specialty
Medicare Defined Swing Bed Hospital UnitTaxonomy code 275N00000X
License
5009B Issued in ND
Legal business name
PEMBINA COUNTY MEMORIAL HOSPITAL ASSOCIATION
Practice address
301 Mountain St E
Cavalier, ND 58220-0380
Phone
(701) 265-8461
Fax
(701) 265-8752
NPI assigned
May 3, 2007
Last updated
Jul 25, 2022By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jul 25, 2022

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Mrs. Lisa R Letexier
Title
Ceo
Phone
(701) 265-6228

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Medicare Defined Swing Bed Hospital Unit 275N00000X 5009B ND Primary

Addresses

Primary practice location

301 Mountain St E
Cavalier, ND 58220-0380

Mailing address

301 Mountain St E
P O Box 380
Cavalier, ND 58220-0380
Phone (701) 265-8461

Other identifiers 3

IdentifierTypeStateIssuer
21379MedicaidND
001960MedicaidND
012443OtherNDND BLUE CROSS SB

Other names 1

  • Pembina County Memorial Hospital Swing Bed Other name

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in ND2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20041006000441 ND Part B Supplier - Clinic/Group Practice 4789643719 Receives reassigned benefits from 15 practitioners
2 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Cavalier, ND
O20081024000629 ND Part A Provider - Critical Access Hospital 4789643719 Practice locations: Cavalier, ND

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1063634210. Details of each certification follow.

Hospital certification: CCN 35Z319

Legal name
PEMBINA COUNTY MEMORIAL HOSPITAL ASSOCIATION
Doing business as
PEMBINA COUNTY MEMORIAL HOSPITAL
Organization structure
CorporationNon-profit
Incorporated
Apr 3, 1946 in ND
Enrollment address
301 Mountain St E
Cavalier, ND 58220-4015
Other Hospital Practice Location

Facilities connected through Provider of Services related, parent or unit certification numbers.

Other NPIs with the same Medicare PAC ID 3

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

Other NPIs on the same Medicare enrollment 2

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

National Provider Directory

National Provider Directory

Ownership & related parties

All disclosed owners & managing parties 12

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Drew Olafson Individual Corporate Director Jun 1, 2023
Susan J Thompson Individual Corporate Director Jan 1, 2021
Larae Horgan Individual Corporate Director Jun 1, 2022
Gordon Johnson Individual Corporate Director Jun 1, 2021
Darin Otto Individual Corporate Director Jun 1, 2022
George Wright Individual Corporate Director Jul 1, 2019
Maggie Beard Individual Corporate Director Jun 1, 2022
Lisa Letexier Individual Contracted Managing Employee Jun 1, 2017
Corporate OfficerCeo Jun 1, 2017
W-2 Managing EmployeeCeo Jun 1, 2017
Thomas Vaughn Individual Corporate Director Aug 23, 2010
Duane Deraas Individual Corporate Director Sep 1, 2019
Nicole Safranski Individual Corporate Director Mar 1, 2016
Katie McDonald Individual Corporate Officer Apr 1, 2019

Owners & managing parties with NPI records 1

Owners and managing parties disclosed on this facility’s Medicare enrollment that are themselves Medicare-enrolled.

All facility ownership & control disclosures 1

Facilities whose Medicare enrollment lists this provider’s PECOS associate ID as an owner or managing party.

FacilityTypeRoleSince
Wedgewood ManorCavalier, ND, CCN 355087 Skilled nursing facility Operational/Managerial Control
Adp of the SNF		 Jan 1, 1980
Apr 3, 1946

Owned or controlled facilities with NPI records 1

Facilities whose Medicare enrollment lists this provider as an owner, officer, director or managing party.

Practitioners & affiliated clinicians

Practitioners 2

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

Affiliated clinicians 2

Clinicians who list this facility as an affiliation in Medicare Care Compare.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1178150400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1658707200000",
    "number": "1063634210",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "301 MOUNTAIN ST E",
            "address_2": "P O BOX 380",
            "city": "CAVALIER",
            "state": "ND",
            "postal_code": "582200380",
            "telephone_number": "701-265-8461",
            "fax_number": "701-265-8752"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "301 MOUNTAIN ST E",
            "city": "CAVALIER",
            "state": "ND",
            "postal_code": "582200380",
            "telephone_number": "701-265-8461",
            "fax_number": "701-265-8752"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PEMBINA COUNTY MEMORIAL HOSPITAL ASSOCIATION",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-05-03",
        "last_updated": "2022-07-25",
        "certification_date": "2022-07-25",
        "status": "A",
        "authorized_official_last_name": "LETEXIER",
        "authorized_official_first_name": "LISA",
        "authorized_official_middle_name": "R",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "701-265-6228",
        "authorized_official_name_prefix": "Mrs."
    },
    "taxonomies": [
        {
            "code": "275N00000X",
            "taxonomy_group": "",
            "desc": "Medicare Defined Swing Bed Unit",
            "state": "ND",
            "license": "5009B",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "21379",
            "state": "ND"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "001960",
            "state": "ND"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "ND BLUE CROSS SB",
            "identifier": "012443",
            "state": "ND"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Pembina County Memorial Hospital Swing Bed",
            "code": "5",
            "type": "Other Name"
        },
        {
            "organization_name": "Pembina County Memorial Hospital Swing Bed",
            "code": "5",
            "type": "Other Name"
        }
    ]
}

Other providers in Cavalier, ND

Sources for this page

Verify at the official NPI Registry.