Basic Information
| Provider Information | |||||||||
| NPI: | 1366650343 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BEAR RIVER VALLEY CARE CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 460 W 600 N | ||||||||
| Address2: | |||||||||
| City: | TREMONTON | ||||||||
| State: | UT | ||||||||
| PostalCode: | 843372400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4352574400 | ||||||||
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| Practice Location | |||||||||
| Address1: | 460 W 600 N | ||||||||
| Address2: | |||||||||
| City: | TREMONTON | ||||||||
| State: | UT | ||||||||
| PostalCode: | 843372400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4352574400 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/21/2007 | ||||||||
| LastUpdateDate: | 06/12/2008 | ||||||||
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| AuthorizedOfficialLastName: | PACKER | ||||||||
| AuthorizedOfficialFirstName: | ERIC | ||||||||
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| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 4352577441 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 311Z00000X | 2007NCF24 | UT | Y | Nursing & Custodial Care Facilities | Custodial Care Facility |
ID Information
| ID | Type | State | Issuer | Description | 942854058564 | 05 | UT | MEDICAID |