Provider Demographics
NPI:1962155135
Name:BASS, KIM
Entity type:Individual
Prefix:
First Name:KIM
Middle Name:
Last Name:BASS
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 1:3409 W WENDOVER AVE STE C
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27407-1579
Mailing Address - Country:US
Mailing Address - Phone:336-687-2657
Mailing Address - Fax:
Practice Address - Street 1:3409 W WENDOVER AVE STE C
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27407-1579
Practice Address - Country:US
Practice Address - Phone:336-687-2657
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-28
Last Update Date:2022-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174H00000XOther Service ProvidersHealth Educator
Provider Identifiers
StateIdentifier IDID TypeIssuer
34D2250561OtherCLIA