Healthcare Provider Details

I. General information

NPI: 1770931891
Provider Name (Legal Business Name): ERIC BASS OT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/31/2016
Last Update Date: 05/31/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 S COULTER ST
AMARILLO TX
79106-1836
US

IV. Provider business mailing address

601 EAGLE BLVD
FRITCH TX
79036-8150
US

V. Phone/Fax

Practice location:
  • Phone: 806-468-9700
  • Fax: 806-468-9771
Mailing address:
  • Phone: 806-433-0212
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number117364
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: