Basic Information
| Provider Information | |||||||||
| NPI: | 1073553756 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BEAR VALLEY COMMUNITY HEALTH CARE DISTRICT | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | BEAR VALLEY COMMUNITY HOSPITAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1649 | ||||||||
| Address2: | |||||||||
| City: | BIG BEAR LAKE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 92315 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9098788276 | ||||||||
| FaxNumber: | 9098788282 | ||||||||
| Practice Location | |||||||||
| Address1: | 41870 GARSTIN DRIVE | ||||||||
| Address2: | |||||||||
| City: | BIG BEAR LAKE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 92315 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9098788276 | ||||||||
| FaxNumber: | 9098788282 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/08/2006 | ||||||||
| LastUpdateDate: | 02/23/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HAMBLIN | ||||||||
| AuthorizedOfficialFirstName: | GARTH | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 9098788276 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 02/23/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X | 240000111 | CA | N | Ambulatory Health Care Facilities | Clinic/Center | Rural Health | 282E00000X | 240000111 | CA | N | Hospitals | Long Term Care Hospital | 3336L0003X | N | Suppliers | Pharmacy | Long Term Care Pharmacy | 282NC0060X | 240000111 | CA | Y | Hospitals | General Acute Care Hospital | Critical Access |
ID Information
| ID | Type | State | Issuer | Description | RHM08614F | 05 | CA | MEDICAID | HSP40618J | 05 | CA | MEDICAID | LTC555468F | 05 | CA | MEDICAID | ZZZ24958Z | 01 | CA | MEDICARE PROFESSIONAL | OTHER | 1073553756 | 05 | CA | MEDICAID | HSP30618J | 05 | CA | MEDICAID | RHM18564F | 05 | CA | MEDICAID |