Provider Demographics
NPI:1104483635
Name:BASOBAS, VINCENT CALUZA
Entity type:Individual
Prefix:
First Name:VINCENT
Middle Name:CALUZA
Last Name:BASOBAS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:141 W 224TH PL
Mailing Address - Street 2:
Mailing Address - City:CARSON
Mailing Address - State:CA
Mailing Address - Zip Code:90745-3707
Mailing Address - Country:US
Mailing Address - Phone:310-612-3480
Mailing Address - Fax:
Practice Address - Street 1:135 N PARK VIEW ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90026-5215
Practice Address - Country:US
Practice Address - Phone:213-908-5050
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-20
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAF6895437OtherDRIVERS LICENSE