1326409343 NPI number — BASS MEDICAL GROUP

Table of content: (NPI 1326409343)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1326409343 NPI number — BASS MEDICAL GROUP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BASS MEDICAL GROUP
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:
1326409343
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/18/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2637 SHADELANDS DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WALNUT CREEK
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
94598-2512
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
925-627-3424
Provider Business Mailing Address Fax Number:
925-627-3560

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5127 W NOBLE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
VISALIA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
93291
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
559-713-6515
Provider Business Practice Location Address Fax Number:
559-713-6516
Provider Enumeration Date:
03/18/2016

Additional Information

Authorized Official

Authorized Official Last Name:
WONDEH
Authorized Official First Name:
INEZ
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
925-378-4512

Provider Taxonomy Codes

  • Taxonomy code: 208VP0000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 7360010007 . This is a "MEDICARE NCS" identifier . This identifiers is of the category "OTHER".




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