Provider Demographics
NPI:1447311139
Name:BEAR LAKE COUNTY
Entity type:Organization
Organization Name:BEAR LAKE COUNTY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:COUNTY CLERK
Authorized Official - Prefix:MR
Authorized Official - First Name:KERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:HADDOCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-945-2212
Mailing Address - Street 1:PO BOX 248
Mailing Address - Street 2:
Mailing Address - City:MONTPELIER
Mailing Address - State:ID
Mailing Address - Zip Code:83254
Mailing Address - Country:US
Mailing Address - Phone:208-847-2274
Mailing Address - Fax:208-847-1189
Practice Address - Street 1:385 CEMETARY ROAD
Practice Address - Street 2:
Practice Address - City:MONTPELIER
Practice Address - State:ID
Practice Address - Zip Code:83254
Practice Address - Country:US
Practice Address - Phone:208-847-2247
Practice Address - Fax:208-847-1189
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-13
Last Update Date:2012-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID7602341600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes341600000XTransportation ServicesAmbulance
Provider Identifiers
StateIdentifier IDID TypeIssuer
E0062OtherBLUE CROSS OF IDAHO
000010014272OtherBLUE SHIELD OF IDAHO
ID002807400Medicaid
WY109956600OtherMEDICAID
000010014272OtherBLUE SHIELD OF IDAHO
UT=========002OtherMEDICAID