Provider Demographics
NPI:1487938791
Name:BASALLA, ROBIN (TVI)
Entity type:Individual
Prefix:
First Name:ROBIN
Middle Name:
Last Name:BASALLA
Suffix:
Gender:F
Credentials:TVI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:402 PACIFIC ST
Mailing Address - Street 2:APT 4
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11217-2290
Mailing Address - Country:US
Mailing Address - Phone:415-378-5525
Mailing Address - Fax:
Practice Address - Street 1:402 PACIFIC ST
Practice Address - Street 2:APT 4
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11217-2290
Practice Address - Country:US
Practice Address - Phone:415-378-5525
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-05
Last Update Date:2011-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1858685152WV0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WV0400XEye and Vision Services ProvidersOptometristVision Therapy