=====================================================
General NPI Number Information
=====================================================
NPI Number | 1598343121
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JOHN L BASS OD PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/02/2021
-----------------------------------------------------
Last Update Date | 04/02/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2702 S HULEN ST
-----------------------------------------------------
City | FORT WORTH
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76109-5590
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-312-9771
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1636 PLEASANT RUN
-----------------------------------------------------
City | KELLER
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76248-5381
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-312-9771
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/PRESIDENT
-----------------------------------------------------
Name | JOHN LESLIE BASS
-----------------------------------------------------
Credential | OD
-----------------------------------------------------
Telephone | 817-312-9771
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------