Healthcare Provider Details

I. General information

NPI: 1063630705
Provider Name (Legal Business Name): BEAR LAKE COMMUNITY HEALTH CENTER, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/20/2007
Last Update Date: 06/01/2022
Certification Date: 06/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1515 N 400 E STE 104
NORTH LOGAN UT
84341-7595
US

IV. Provider business mailing address

517 W 100 N STE 210
PROVIDENCE UT
84332-9826
US

V. Phone/Fax

Practice location:
  • Phone: 435-946-3660
  • Fax:
Mailing address:
  • Phone: 435-946-3660
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State

VIII. Authorized Official

Name: JORGE GARCIA
Title or Position: CEO
Credential:
Phone: 435-755-6061