Provider Demographics
NPI:1952500605
Name:BEAR RIVER DISTRICT HEALTH DEPARTMENT
Entity Type:Organization
Organization Name:BEAR RIVER DISTRICT HEALTH DEPARTMENT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:LLOYD
Authorized Official - Middle Name:
Authorized Official - Last Name:BERENTZEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:435-792-6500
Mailing Address - Street 1:655 E 1300 N
Mailing Address - Street 2:
Mailing Address - City:LOGAN
Mailing Address - State:UT
Mailing Address - Zip Code:84341
Mailing Address - Country:US
Mailing Address - Phone:435-792-6500
Mailing Address - Fax:
Practice Address - Street 1:655 E 1300 N
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84341
Practice Address - Country:US
Practice Address - Phone:435-792-6500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-13
Last Update Date:2007-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT998877668007Medicaid