Provider Demographics
NPI:1104904804
Name:ERIC J BASS OD PROFESSIONAL CORP
Entity type:Organization
Organization Name:ERIC J BASS OD PROFESSIONAL CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:
Authorized Official - Last Name:BASS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:714-898-5631
Mailing Address - Street 1:15068 GOLDENWEST ST
Mailing Address - Street 2:
Mailing Address - City:WESTMINSTER
Mailing Address - State:CA
Mailing Address - Zip Code:92683-6152
Mailing Address - Country:US
Mailing Address - Phone:714-898-5631
Mailing Address - Fax:714-898-4771
Practice Address - Street 1:15068 GOLDENWEST ST
Practice Address - Street 2:
Practice Address - City:WESTMINSTER
Practice Address - State:CA
Practice Address - Zip Code:92683-6152
Practice Address - Country:US
Practice Address - Phone:714-898-5631
Practice Address - Fax:714-898-4771
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2014-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA8249T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGSD000830Medicaid
CA6893320001Medicare NSC
CACB212253Medicare PIN