Provider Demographics
NPI:1740598614
Name:BEAR LAKE MEMORIAL HOSPITAL
Entity Type:Organization
Organization Name:BEAR LAKE MEMORIAL HOSPITAL
Other - Org Name:BEAR LAKE MANOR
Other - Org Type:Doing Business As
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:208-847-0920
Mailing Address - Street 1:855 BOISE ST
Mailing Address - Street 2:
Mailing Address - City:MONTPELIER
Mailing Address - State:ID
Mailing Address - Zip Code:83254-1070
Mailing Address - Country:US
Mailing Address - Phone:208-847-2400
Mailing Address - Fax:
Practice Address - Street 1:855 BOISE ST
Practice Address - Street 2:
Practice Address - City:MONTPELIER
Practice Address - State:ID
Practice Address - Zip Code:83254-1070
Practice Address - Country:US
Practice Address - Phone:208-847-2400
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-14
Last Update Date:2010-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDRC-738310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID806513000Medicaid