Provider Demographics
NPI:1669521084
Name:BEAR LAKE COUNTY MEMORIAL HOSPITAL
Entity type:Organization
Organization Name:BEAR LAKE COUNTY MEMORIAL HOSPITAL
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF HOME HEALTH
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHAUNA
Authorized Official - Middle Name:
Authorized Official - Last Name:DAWES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-847-4454
Mailing Address - Street 1:164 S 5TH ST
Mailing Address - Street 2:
Mailing Address - City:MONTPELIER
Mailing Address - State:ID
Mailing Address - Zip Code:83254-1557
Mailing Address - Country:US
Mailing Address - Phone:208-847-4454
Mailing Address - Fax:208-847-4414
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:208-847-4454
Practice Address - Fax:208-847-4414
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BEAR LAKE COUNTY MEMORIAL HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-01-09
Last Update Date:2015-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDHH107251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID002853200Medicaid
ID137069Medicare ID - Type UnspecifiedHOME HEALTH