Provider Demographics
NPI:1851455224
Name:BONNEVILLE DIALYSIS CENTER
Entity type:Organization
Organization Name:BONNEVILLE DIALYSIS CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL ADMIN. MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:STEVE
Authorized Official - Middle Name:
Authorized Official - Last Name:SUTCH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-587-7606
Mailing Address - Street 1:PO BOX 27071
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84127-0071
Mailing Address - Country:US
Mailing Address - Phone:801-581-8578
Mailing Address - Fax:
Practice Address - Street 1:5575 S 500 E
Practice Address - Street 2:
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84405-6907
Practice Address - Country:US
Practice Address - Phone:801-479-0351
Practice Address - Fax:801-476-1766
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Multi-Specialty
Not Answered246ZN0300XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherNephrologyGroup - Multi-Specialty
Not Answered2472R0900XTechnologists, Technicians & Other Technical Service ProvidersTechnician, OtherRenal DialysisGroup - Multi-Specialty
Not Answered363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
Not Answered363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT=========001Medicaid
UT=========001Medicaid