NPIMap

Organization Active NPI

Kremmling Memorial Hospital District

Doing business as Middle Park Health - Grand Lake Clinic

  • Rural Health Clinic/Center
  • Grand Lake, CO
National Provider Identifier
1740839240
Registry record updated Jan 25, 2021
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rural Health Clinic/CenterTaxonomy code 261QR1300X
Legal business name
KREMMLING MEMORIAL HOSPITAL DISTRICT
Doing business as
Middle Park Health - Grand Lake Clinic
Practice address
301 Marina Drive
Grand Lake, CO 80447-0000
Phone
(970) 557-6044
Fax
(970) 724-9446
NPI assigned
Sep 6, 2019
Last updated
Jan 25, 2021By the provider in NPPES
Organization subpart
Yes
Parent organization
KREMMLING MEMORIAL HOSPITAL DISTRICTAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Jan 25, 2021

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

Authorized official

Name
Kelly S Clasen
Title
Sr. Director, Business Operations
Phone
(307) 699-2413

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Rural Health Clinic/Center 261QR1300X Primary

Addresses

Primary practice location

301 Marina Drive
Grand Lake, CO 80447-0000

Mailing address

PO Box 399
Kremmling, CO 80459-0399
Phone (970) 724-3171

Other identifiers 1

IdentifierTypeStateIssuer
9000141155MedicaidCO

Other names 1

  • Middle Park Health - Grand Lake Clinic Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in CO

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20200812000230 CO Part A Provider - Rural Health Clinic 7517871544 1 other NPI on this enrollment
Practice locations: Grand Lake, CO

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1740839240. Details of each certification follow.

Rural health clinic certification: CCN 063421

Legal name
KREMMLING MEMORIAL HOSPITAL DISTRICT
Doing business as
MIDDLE PARK HEALTH-GRAND LAKE CLINIC
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Jul 8, 2020
Last certification
Jun 1, 2023
Ownership / control type
Non-profit – church related
Organization structure
OtherNon-profit
Incorporated
Jun 20, 1973 in CO
Enrollment address
301 Marina Drive
Grand Lake, CO 80447-0000
Related CCNs
061318

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

Other NPIs with the same Medicare PAC ID 5

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

Other NPIs on the same Medicare enrollment 1

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

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
06D2167299Middle Park Health - Grand Lake301 Marina Dr, Grand Lake, CO 80447Certificate of waiverOct 14, 2027

National Provider Directory

National Provider Directory
Tax ID family
Kremmling Memorial Hospital District17 organizations share this tax ID, including this one
Part of
Kremmling Memorial Hospital District

Other organizations with this tax ID 16

Organizations that report the same tax identification number in the National Provider Directory.

View all 16

Ownership & related parties

All disclosed owners & managing parties 3

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

NameRoleSinceShare
Mikealena S Horner Individual W-2 Managing EmployeeDirector of Finance Jun 18, 2019
Jason Cleckler Individual Corporate OfficerCeo Feb 1, 2020 10%
Kremmling Memorial Hospital District Organization, Kremmling, CO Non-profit 5% Or Greater Direct Ownership Interest Jun 20, 1973 100%

Owners & managing parties with NPI records 5

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

All facility ownership & control disclosures 2

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

FacilityTypeRoleSince
Middle Park Medical CenterKremmling, CO, CCN 061318 Hospital Operational/Managerial Control Mar 1, 2003
North Park Medical Center-WaldenWalden, CO, CCN 068518 Rural health clinic Operational/Managerial Control (100%) Feb 1, 2012

Owned or controlled facilities with NPI records 7

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

Facilities with the same owner 2

Facilities that share an organizational owner with 5% or greater ownership or operational control.

Parent organization (reported in NPPES) 1

This organization reports itself as a subpart in NPPES; the parent’s legal name matches this organization in the same state.

NPI Registry JSON

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

{
    "created_epoch": "1567728000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1611532800000",
    "number": "1740839240",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 399",
            "city": "KREMMLING",
            "state": "CO",
            "postal_code": "804590399",
            "telephone_number": "970-724-3171",
            "fax_number": "970-724-9446"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "301 MARINA DRIVE",
            "city": "GRAND LAKE",
            "state": "CO",
            "postal_code": "804470000",
            "telephone_number": "970-557-6044",
            "fax_number": "970-724-9446"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "KREMMLING MEMORIAL HOSPITAL DISTRICT",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "KREMMLING MEMORIAL HOSPITAL DISTRICT",
        "enumeration_date": "2019-09-06",
        "last_updated": "2021-01-25",
        "certification_date": "2021-01-25",
        "status": "A",
        "authorized_official_last_name": "CLASEN",
        "authorized_official_first_name": "KELLY",
        "authorized_official_middle_name": "S",
        "authorized_official_title_or_position": "SR. DIRECTOR, BUSINESS OPERATIONS",
        "authorized_official_telephone_number": "307-699-2413"
    },
    "taxonomies": [
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "9000141155",
            "state": "CO"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Middle Park Health - Grand Lake Clinic",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Grand Lake, CO

Sources for this page

Verify at the official NPI Registry.