Healthcare Provider Details

I. General information

NPI: 1568952190
Provider Name (Legal Business Name): BEAR RIVER VALLEY MEDICAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/18/2018
Last Update Date: 01/02/2025
Certification Date: 01/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9825 N 10800 W
TREMONTON UT
84337-9222
US

IV. Provider business mailing address

9825 N 10800 W
TREMONTON UT
84337-9222
US

V. Phone/Fax

Practice location:
  • Phone: 888-851-3677
  • Fax:
Mailing address:
  • Phone: 907-341-9751
  • Fax: 866-311-6889

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZE0600X
TaxonomyElectroneurodiagnostic Specialist/Technologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: TERESA CARTER
Title or Position: DIRECTOR OF BILLING
Credential:
Phone: 907-341-9751