Healthcare Provider Details

I. General information

NPI: 1891483541
Provider Name (Legal Business Name): RANDY BASS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/28/2023
Last Update Date: 04/28/2023
Certification Date: 04/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10133 SHERRILL BLVD STE 200
KNOXVILLE TN
37932-3347
US

IV. Provider business mailing address

10133 SHERRILL BLVD STE 200
KNOXVILLE TN
37932-3347
US

V. Phone/Fax

Practice location:
  • Phone: 888-531-2204
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XG0600X
TaxonomyGerontology Occupational Therapist
License Number115273
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: