Provider Demographics
NPI:1699584508
Name:BASILIS, TORY
Entity type:Individual
Prefix:
First Name:TORY
Middle Name:
Last Name:BASILIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 55
Mailing Address - Street 2:
Mailing Address - City:LAKE GENEVA
Mailing Address - State:FL
Mailing Address - Zip Code:32160-0055
Mailing Address - Country:US
Mailing Address - Phone:352-316-2922
Mailing Address - Fax:
Practice Address - Street 1:5998 CENTRE ST STE F
Practice Address - Street 2:
Practice Address - City:MELROSE
Practice Address - State:FL
Practice Address - Zip Code:32666-6208
Practice Address - Country:US
Practice Address - Phone:352-316-2922
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-06
Last Update Date:2025-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA73666172M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172M00000XOther Service ProvidersMechanotherapist