- Enrollment id
- O20050503001168
- Enrollment state
- ID
- Provider type code
- 00-06
- Provider type text
- PART A PROVIDER - HOME HEALTH AGENCY
- Npi
- 1669521084
- Multiple npi flag
- N
- Ccn
- 137069
- Associate id
- 5395799860
- Organization name
- BEAR LAKE COUNTY MEMORIAL HOSPITAL
- Doing business as name
- BEAR LAKE COUNTY MEMORIAL HOSPITAL HOME HEALTH
- Organization type structure
- OTHER
- Organization other type text
- NON PROFIT COUNTY HOSPITAL
- Proprietary nonprofit
- N
- Address line 1
- 164 S 5TH ST
- City
- MONTPELIER
- State
- ID
- Zip code
- 832541557