Healthcare Provider Details

I. General information

NPI: 1376325001
Provider Name (Legal Business Name): PROVIDENTIAL BBA OPERATING LP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/17/2023
Last Update Date: 10/17/2023
Certification Date: 10/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 S 400 E
BOUNTIFUL UT
84010-4933
US

IV. Provider business mailing address

481 S 400 E
BOUNTIFUL UT
84010-4933
US

V. Phone/Fax

Practice location:
  • Phone: 801-397-8145
  • Fax: 201-294-5877
Mailing address:
  • Phone: 801-397-8145
  • Fax: 801-294-5877

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code207RH0002X
TaxonomyHospice and Palliative Medicine (Internal Medicine) Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: MICHELLE BROWN
Title or Position: CFO
Credential: CFO
Phone: 801-397-8145