Provider Demographics
NPI:1194334862
Name:BASS, MATTHEW RICHARD (PT, DPT)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:RICHARD
Last Name:BASS
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:402 E LIBERTY DR
Mailing Address - Street 2:
Mailing Address - City:WHEATON
Mailing Address - State:IL
Mailing Address - Zip Code:60187-5511
Mailing Address - Country:US
Mailing Address - Phone:720-592-5310
Mailing Address - Fax:
Practice Address - Street 1:27TH SPECIAL OPERATIONS MEDICAL GROUP
Practice Address - Street 2:224 W D. L. INGRAM AVENUE, BLDG. 1408
Practice Address - City:CANNON AFB
Practice Address - State:NM
Practice Address - Zip Code:88103
Practice Address - Country:US
Practice Address - Phone:720-592-5310
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-28
Last Update Date:2024-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO17033225100000X, 2251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist