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BEAR LAKE COMMUNITY HEALTH CENTER, INC.

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Company Details

Name: BEAR LAKE COMMUNITY HEALTH CENTER, INC.
Jurisdiction: Idaho
Legal type: Foreign Nonprofit Corporation
Status: Inactive-Revoked (Administrative)
Date of registration: 19 Jun 2015 (10 years ago)
Financial Date End: 30 Jun 2023
Date dissolved: 16 Sep 2023
Entity Number: 621074
Place of Formation: UTAH
File Number: 621074
Principal Address: 517 W 100 N STE 210 PROVIDENCE, UT 84332
Mailing Address: CORY A WENGREEN STE 225 517 W 100 N PROVIDENCE, UT 84332-9826

Director

Name Role Address Appointed On
LaVal B Jensen Director 517 WEST 100 NORTH, PROVIDENCE, UT 84332 2021-07-12
Roy Bunderson Director 517 WEST 100 NORTH, PROVIDENCE, UT 84332 2022-08-12

National Provider Identifier

NPI Number:
1003264664
Certification Date:
2022-06-01

Authorized Person:

Name:
JORGE GARCIA
Role:
CEO
Phone:

Taxonomy:

Selected Taxonomy:
261QF0400X - Federally Qualified Health Center (FQHC)
Is Primary:
Yes

Contacts:

Fax:
3549948362
Fax:
2088472109

Filing

Filing Name Filing Number Filing date
Dissolution/Revocation - Administrative 0005403472 2023-09-16
Annual Report 0004860282 2022-08-12
Annual Report 0004344913 2021-07-12
Annual Report 0003908171 2020-06-12
Annual Report 0003558003 2019-07-02

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Date of last update: 05 Jul 2025

Sources: Idaho Secretary of State