Provider Demographics
NPI:1598871337
Name:BESSA, INC
Entity Type:Organization
Organization Name:BESSA, INC
Other - Org Name:UINTAH BASIN DIALYSIS CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:EDWIN
Authorized Official - Middle Name:C
Authorized Official - Last Name:BULLOCH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:435-722-5056
Mailing Address - Street 1:384 NORTH 100 WEST (74-6)
Mailing Address - Street 2:
Mailing Address - City:ROOSEVELT
Mailing Address - State:UT
Mailing Address - Zip Code:84066
Mailing Address - Country:US
Mailing Address - Phone:435-722-5056
Mailing Address - Fax:435-722-0779
Practice Address - Street 1:384 NORTH 100 WEST #74-6
Practice Address - Street 2:
Practice Address - City:ROOSEVELT
Practice Address - State:UT
Practice Address - Zip Code:84066
Practice Address - Country:US
Practice Address - Phone:435-722-5056
Practice Address - Fax:435-722-0779
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT2005-ESRD-229261QE0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT87035602601001OtherBLUE CROSS BLUE SHIELD PR
UT870356026005Medicaid
UT87035602601001OtherBLUE CROSS BLUE SHIELD PR