1376608562 NPI number — KREMMLING MERCANTILE LLC

Table of content: (NPI 1376608562)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1376608562 NPI number — KREMMLING MERCANTILE LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KREMMLING MERCANTILE LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
KREMMLING MERCANTILE
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1376608562
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/18/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1600
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KREMMLING
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
80459-1600
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
101 MARTIN WAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KREMMLING
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
80459
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
970-724-3205
Provider Business Practice Location Address Fax Number:
970-724-3225
Provider Enumeration Date:
12/27/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
HAMMER
Authorized Official First Name:
KAREN
Authorized Official Middle Name:
Authorized Official Title or Position:
CONTROLLER
Authorized Official Telephone Number:
970-724-3400

Provider Taxonomy Codes

  • Taxonomy code: 333600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: 623 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 2003836 . This is a "PK" identifier . This identifiers is of the category "OTHER".
  • Identifier: 28929039 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".