Basic Information
| Provider Information | |||||||||
| NPI: | 1518149152 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MISSION HEALTH SERVICES | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | BEAR RIVER VALLEY CARE CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 460 W 600 N | ||||||||
| Address2: | |||||||||
| City: | TREMONTON | ||||||||
| State: | UT | ||||||||
| PostalCode: | 843372400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4352574400 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 460 W 600 N | ||||||||
| Address2: | |||||||||
| City: | TREMONTON | ||||||||
| State: | UT | ||||||||
| PostalCode: | 843372400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4352574400 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/05/2007 | ||||||||
| LastUpdateDate: | 08/18/2014 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | KELSO | ||||||||
| AuthorizedOfficialFirstName: | GARY | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8017452348 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MISSION HEALTH SERVICES | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 313M00000X | 2007 NCF 82143 | UT | Y | Nursing & Custodial Care Facilities | Nursing Facility/Intermediate Care Facility |
ID Information
| ID | Type | State | Issuer | Description | 1366650343 | 05 | UT | MEDICAID |