Provider Demographics
NPI:1689241762
Name:BEAR LAKE COMMUNITY HEALTH CENTER, INC.
Entity Type:Organization
Organization Name:BEAR LAKE COMMUNITY HEALTH CENTER, INC.
Other - Org Name:BEAR LAKE COMMUNITY HEALTH CENTER - RANDOLPH
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 1:120 S MAIN ST
Practice Address - Street 2:
Practice Address - City:RANDOLPH
Practice Address - State:UT
Practice Address - Zip Code:84064-7701
Practice Address - Country:US
Practice Address - Phone:435-755-6061
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-06-08
Last Update Date:2022-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)