Provider Demographics
NPI:1235495771
Name:BEAR LAKE COMMUNITY HEALTH CENTER, INC.
Entity Type:Organization
Organization Name:BEAR LAKE COMMUNITY HEALTH CENTER, INC.
Other - Org Name:EVANSTON COMMUNITY HEALTH CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JORGE
Authorized Official - Middle Name:
Authorized Official - Last Name:GARCIA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:435-755-6061
Mailing Address - Street 1:517 W 100 N STE 210
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:UT
Mailing Address - Zip Code:84332-9826
Mailing Address - Country:US
Mailing Address - Phone:435-755-6061
Mailing Address - Fax:354-994-8362
Practice Address - Street 1:75 YELLOW CREEK RD
Practice Address - Street 2:SUITE 102
Practice Address - City:EVANSTON
Practice Address - State:WY
Practice Address - Zip Code:82930-5235
Practice Address - Country:US
Practice Address - Phone:307-789-8290
Practice Address - Fax:307-789-8975
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-10
Last Update Date:2022-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)Group - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY531817Medicare Oscar/Certification
WYW24280Medicare PIN