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NPI Code Detail

MEDICARE: BEAR LAKE COMMUNITY HEALTH CENTER, INC.

MEDICARE: BEAR LAKE COMMUNITY HEALTH CENTER, INC.
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1261QF0400XFederally Qualified Health Center (FQHC)

General Provider Information

NPI Number : 1649546938
Entity Type Code : Organization
Provider Name (Legal Business Name) : BEAR LAKE COMMUNITY HEALTH CENTER, INC.
Provider Business Mailing Address
First Line : 517 W 100 N STE 210
Second Line :
City : PROVIDENCE
State : UT
Zip : 84332-9826
Country : US
Telephone Number : 435-755-6061
Fax Number : 435-994-8362
Provider Business Practice Location Address
First Line : 517 W 100 N STE 110
Second Line :
City : PROVIDENCE
State : UT
Zip : 84332-9826
Country : US
Telephone Number : 435-755-6075
Fax Number : 435-994-8362
Authorized Official
Title or Position : CEO
Name : JORGE GARCIA
Credential :
Telephone Number : 435-755-6061
Provider Enumeration Date : 03/30/2012
Last Update Date : 06/06/2022

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