Healthcare Provider Details

I. General information

NPI: 1023923059
Provider Name (Legal Business Name): SERIC BASS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/14/2026
Last Update Date: 08/14/2026
Certification Date: 08/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

527 LINCOLN RD W
VALLEJO CA
94590-7144
US

IV. Provider business mailing address

1414 LEMON ST
VALLEJO CA
94590-7331
US

V. Phone/Fax

Practice location:
  • Phone: 707-641-6480
  • Fax:
Mailing address:
  • Phone: 707-641-6480
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number002792991
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: