Provider Demographics
NPI:1497815310
Name:CAVALIER COUNTY MEMORIAL HOSPITAL ASSOCIATION
Entity Type:Organization
Organization Name:CAVALIER COUNTY MEMORIAL HOSPITAL ASSOCIATION
Other - Org Name:CAVALIER COUNTY MEMORIAL HOSPTIAL - WALHALLA CLINIC
Other - Org Type:Other Name
Authorized Official - Title/Position:ADMINISTRATOR/CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JEFFERY
Authorized Official - Middle Name:
Authorized Official - Last Name:STANLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:701-256-6180
Mailing Address - Street 1:909 2ND ST
Mailing Address - Street 2:
Mailing Address - City:LANGDON
Mailing Address - State:ND
Mailing Address - Zip Code:58249-2407
Mailing Address - Country:US
Mailing Address - Phone:701-256-6100
Mailing Address - Fax:701-256-2170
Practice Address - Street 1:301 5TH ST
Practice Address - Street 2:
Practice Address - City:WALHALLA
Practice Address - State:ND
Practice Address - Zip Code:58282-4625
Practice Address - Country:US
Practice Address - Phone:701-549-2711
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CAVALIER COUNTY MEMORIAL HOSPITAL ASSOC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-12-11
Last Update Date:2019-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND5029261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND1470144Medicaid
NDN1000054Medicare PIN
NDN1000054Medicare PIN