Provider Demographics
NPI:1043649486
Name:JACOBSON MEMORIAL HOSPITAL CARE CENTER
Entity Type:Organization
Organization Name:JACOBSON MEMORIAL HOSPITAL CARE CENTER
Other - Org Name:RICHARDTON CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:THEO
Authorized Official - Middle Name:
Authorized Official - Last Name:STOLLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:701-584-2792
Mailing Address - Street 1:PO BOX 367
Mailing Address - Street 2:
Mailing Address - City:ELGIN
Mailing Address - State:ND
Mailing Address - Zip Code:58533
Mailing Address - Country:US
Mailing Address - Phone:701-584-2792
Mailing Address - Fax:701-584-2397
Practice Address - Street 1:215 3RD AVE W
Practice Address - Street 2:
Practice Address - City:RICHARDTON
Practice Address - State:ND
Practice Address - Zip Code:58652-7109
Practice Address - Country:US
Practice Address - Phone:701-974-3372
Practice Address - Fax:701-584-2397
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:JACOBSON MEMORIAL HOSPITAL CARE CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-11-06
Last Update Date:2019-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND1452461Medicaid
353899Medicare Oscar/Certification
N711274Medicare Oscar/Certification