Provider Demographics
NPI:1578682522
Name:GOLDEN VALLEY MEMORIAL HOSPITAL
Entity Type:Organization
Organization Name:GOLDEN VALLEY MEMORIAL HOSPITAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:RANDY
Authorized Official - Middle Name:
Authorized Official - Last Name:WERTZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:660-890-7103
Mailing Address - Street 1:1600 N 2ND ST
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:MO
Mailing Address - Zip Code:64735-1192
Mailing Address - Country:US
Mailing Address - Phone:660-890-7103
Mailing Address - Fax:660-885-8496
Practice Address - Street 1:1600 N 2ND ST
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:MO
Practice Address - Zip Code:64735-1192
Practice Address - Country:US
Practice Address - Phone:660-890-7103
Practice Address - Fax:660-885-8496
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-29
Last Update Date:2016-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO257-35341600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes341600000XTransportation ServicesAmbulance
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO800565608Medicaid