Organization
BESSA, INC
Active
Other names
Uintah Basin Dialysis Center
Organization subpart
No
Provider details
NPI number
Authorized official
MR. EDWIN C BULLOCH (ADMINISTRATOR)
(435) 722-5056
Entity
Organization
Contact information
Practice address
384 NORTH 100 WEST #74-6, ROOSEVELT, UT 84066
(435) 722-5056
(435) 722-0779
Mailing address
384 NORTH 100 WEST (74-6), ROOSEVELT, UT 84066
(435) 722-5056
(435) 722-0779
Taxonomy
Speciality
Code
Description
License number
State
261QE0700X
End-Stage Renal Disease (ESRD) Treatment Clinic/Center
Primary
2005-ESRD-229
UT
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
870356026005
—
UT
01
—
87035602601001
BLUE CROSS BLUE SHIELD PR
UT
Enumeration date
08/22/2006
Last updated
08/22/2020
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