1629587555 NPI number — BASS CHIROPRACTIC PROFESSIONAL CORP

Table of content: (NPI 1629587555)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629587555 NPI number — BASS CHIROPRACTIC PROFESSIONAL CORP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BASS CHIROPRACTIC PROFESSIONAL CORP
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1629587555
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/18/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1176
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CARDIFF
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92007-7176
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
858-509-7999
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8455 BEVERLY BLVD STE 505
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LOS ANGELES
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90048-3445
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
323-944-0773
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/22/2017

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
BASS
Authorized Official First Name:
MARISSA
Authorized Official Middle Name:
NICOLE
Authorized Official Title or Position:
OWNER/CHIROPRACTOR
Authorized Official Telephone Number:
323-944-0773

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: DC31978 . This is a "CHIRO LICENSE" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".