| Organization Name: | BEAR LAKE COMMUNITY HEALTH CENTERS |
| NPI Number: | 1003264664 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | LAVAL B JENSEN (CEO) |
| Mailing Address: | 152 S 4th St Montpelier |
| State: | ID US |
| Postal Code: | 832541538 |
| Phone Number: | 2088472108 |
| Fax Number: | 2088472109 |
| NPI Enumeration Date: | 05/24/2016 |
| NPI Last Update Date: | 05/24/2016 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 261QF0400X |
| License Number: | |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | |
| Taxonomy Type: | Ambulatory Health Care Facilities |
| Taxonomy Classification: | Clinic/Center |
| Taxonomy Specialization: | Federally Qualified Health Center (FQHC) |
| Taxonomy Definition: | |