Provider Demographics
NPI:1659461531
Name:BEAR LAKE COUNTY MEMORIAL HOSPITAL
Entity Type:Organization
Organization Name:BEAR LAKE COUNTY MEMORIAL HOSPITAL
Other - Org Name:BEAR LAKE MEMORIAL SWING BED
Other - Org Type:Other Name
Authorized Official - Title/Position:PFS DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:
Authorized Official - Last Name:MESSERLY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-847-4429
Mailing Address - Street 1:164 SOUTH 5TH
Mailing Address - Street 2:
Mailing Address - City:MONTPELIER
Mailing Address - State:ID
Mailing Address - Zip Code:83254
Mailing Address - Country:US
Mailing Address - Phone:208-847-4412
Mailing Address - Fax:208-847-4428
Practice Address - Street 1:164 S 5TH ST
Practice Address - Street 2:
Practice Address - City:MONTPELIER
Practice Address - State:ID
Practice Address - Zip Code:83254-1557
Practice Address - Country:US
Practice Address - Phone:208-847-4412
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-13
Last Update Date:2010-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID13Z316Medicare ID - Type Unspecified