Healthcare Provider Details

I. General information

NPI: 1659461531
Provider Name (Legal Business Name): BEAR LAKE COUNTY MEMORIAL HOSPITAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/13/2006
Last Update Date: 05/19/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

164 S 5TH ST
MONTPELIER ID
83254-1557
US

IV. Provider business mailing address

164 SOUTH 5TH
MONTPELIER ID
83254
US

V. Phone/Fax

Practice location:
  • Phone: 208-847-4412
  • Fax:
Mailing address:
  • Phone: 208-847-4412
  • Fax: 208-847-4428

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number State

VIII. Authorized Official

Name: RYAN MESSERLY
Title or Position: PFS DIRECTOR
Credential:
Phone: 208-847-4429