Provider Demographics
NPI:1215970835
Name:PROVIDENTIAL BBA OPERATING LP
Entity type:Organization
Organization Name:PROVIDENTIAL BBA OPERATING LP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:A
Authorized Official - Last Name:BLAND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-397-8101
Mailing Address - Street 1:401 SOUTH 400 EAST
Mailing Address - Street 2:
Mailing Address - City:BOUNTIFUL
Mailing Address - State:UT
Mailing Address - Zip Code:84010-4933
Mailing Address - Country:US
Mailing Address - Phone:801-295-2361
Mailing Address - Fax:801-295-1398
Practice Address - Street 1:481 SOUTH 400 EAST
Practice Address - Street 2:
Practice Address - City:BOUNTIFUL
Practice Address - State:UT
Practice Address - Zip Code:84010-8401
Practice Address - Country:US
Practice Address - Phone:801-295-2361
Practice Address - Fax:801-295-1398
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-13
Last Update Date:2020-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT2006HOSPICE842251G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1215970835Medicaid
UT=========Medicaid