=====================================================
General NPI Number Information
=====================================================
NPI Number | 1760081756
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARK A BASS SR.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/21/2020
-----------------------------------------------------
Last Update Date | 10/21/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2301 PHILADELPHIA DR
-----------------------------------------------------
City | DAYTON
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45406-1816
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 313-657-3384
-----------------------------------------------------
Fax | 614-987-8649
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 2204
-----------------------------------------------------
City | DAYTON
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45401-2204
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 313-657-3384
-----------------------------------------------------
Fax | 614-987-8649
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 343900000X
-----------------------------------------------------
Taxonomy Name | Non-emergency Medical Transport (VAN)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------