Provider Demographics
NPI:1477692119
Name:BESSA, INC
Entity Type:Organization
Organization Name:BESSA, INC
Other - Org Name:MT. VIEW DIALYSIS CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:EDWIN
Authorized Official - Middle Name:C
Authorized Official - Last Name:BULLOCH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:435-781-2335
Mailing Address - Street 1:209 N 300 W
Mailing Address - Street 2:
Mailing Address - City:VERNAL
Mailing Address - State:UT
Mailing Address - Zip Code:84078-1927
Mailing Address - Country:US
Mailing Address - Phone:435-781-2335
Mailing Address - Fax:435-781-0153
Practice Address - Street 1:209 N 300 W
Practice Address - Street 2:
Practice Address - City:VERNAL
Practice Address - State:UT
Practice Address - Zip Code:84078-1927
Practice Address - Country:US
Practice Address - Phone:435-781-2335
Practice Address - Fax:435-781-0153
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UTESRD-22801261QE0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT22805000000001OtherBXBS PROVIDER #
UT=========001Medicaid
UT462527Medicare ID - Type UnspecifiedMEDICARE ID #