Provider Demographics
NPI: | 1629309786 |
---|---|
Name: | BEAR LAKE COMMUNITY HEALTH CENTER, INC. |
Entity Type: | Organization |
Organization Name: | BEAR LAKE COMMUNITY HEALTH CENTER, INC. |
Other - Org Name: | ROCK SPRINGS 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: | 435-994-8362 |
Practice Address - Street 1: | 325 WEST LOGAN HIGHWAY |
Practice Address - Street 2: | |
Practice Address - City: | GARDEN CITY |
Practice Address - State: | UT |
Practice Address - Zip Code: | 84028-8001 |
Practice Address - Country: | US |
Practice Address - Phone: | 435-946-3660 |
Practice Address - Fax: | 435-946-8215 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2010-01-28 |
Last Update Date: | 2022-06-06 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
104100000X, 106H00000X, 122300000X, 1223G0001X, 133V00000X, 152W00000X, 1835P1300X, 207Q00000X, 207V00000X, 2084P0804X, 363A00000X, 363L00000X, 363LF0000X, 363LP0808X | ||
UT | 59537721204 | 207Q00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 207Q00000X | Allopathic & Osteopathic Physicians | Family Medicine | Group - Multi-Specialty | |
No | 104100000X | Behavioral Health & Social Service Providers | Social Worker | Group - Multi-Specialty | |
No | 106H00000X | Behavioral Health & Social Service Providers | Marriage & Family Therapist | Group - Multi-Specialty | |
No | 122300000X | Dental Providers | Dentist | Group - Multi-Specialty | |
No | 1223G0001X | Dental Providers | Dentist | General Practice | Group - Multi-Specialty |
No | 133V00000X | Dietary & Nutritional Service Providers | Dietitian, Registered | Group - Multi-Specialty | |
No | 152W00000X | Eye and Vision Services Providers | Optometrist | Group - Multi-Specialty | |
No | 1835P1300X | Pharmacy Service Providers | Pharmacist | Psychiatric | Group - Multi-Specialty |
No | 207V00000X | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Group - Multi-Specialty | |
No | 2084P0804X | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Child & Adolescent Psychiatry | Group - Multi-Specialty |
No | 363A00000X | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Group - Multi-Specialty | |
No | 363L00000X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Group - Multi-Specialty | |
No | 363LF0000X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | Group - Multi-Specialty |
No | 363LP0808X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psychiatric/Mental Health | Group - Multi-Specialty |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
UT | 000057477 | Medicare PIN | |
WY | W24280 | Medicare PIN |