Provider Demographics
NPI:1457321176
Name:CLEARWATER COUNTY MEMORIAL HOSPITAL
Entity Type:Organization
Organization Name:CLEARWATER COUNTY MEMORIAL HOSPITAL
Other - Org Name:CLEARWATER HEALTH SERVICES CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMIN SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:NORA
Authorized Official - Middle Name:C
Authorized Official - Last Name:JENNINGS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:218-694-6501
Mailing Address - Street 1:123 4TH ST NW
Mailing Address - Street 2:
Mailing Address - City:BAGLEY
Mailing Address - State:MN
Mailing Address - Zip Code:56621-8306
Mailing Address - Country:US
Mailing Address - Phone:218-694-2384
Mailing Address - Fax:218-694-6687
Practice Address - Street 1:123 4TH ST NW
Practice Address - Street 2:
Practice Address - City:BAGLEY
Practice Address - State:MN
Practice Address - Zip Code:56621-8306
Practice Address - Country:US
Practice Address - Phone:218-694-2384
Practice Address - Fax:218-694-6687
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-25
Last Update Date:2012-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN879685800Medicaid
MNC02762Medicare ID - Type Unspecified
MNCH7722Medicare PIN
MN879685800Medicaid