Provider Demographics
NPI:1205971447
Name:MKB MANAGEMENT CORPORATION
Entity type:Organization
Organization Name:MKB MANAGEMENT CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:TAMMI
Authorized Official - Middle Name:J
Authorized Official - Last Name:KROMENAKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:701-298-9999
Mailing Address - Street 1:512 1ST AVE N
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58102-4804
Mailing Address - Country:US
Mailing Address - Phone:701-298-9999
Mailing Address - Fax:701-235-8084
Practice Address - Street 1:512 1ST AVE N
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58102-4804
Practice Address - Country:US
Practice Address - Phone:701-298-9999
Practice Address - Fax:701-235-8084
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0005XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Family Planning Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND10975Medicaid
MN07-83107OtherMEDICA ID #
MN09G07REOtherBCBS ID #