Provider Demographics
NPI:1730386640
Name:BASILISCO, JOFFREE J (PT)
Entity type:Individual
Prefix:MR
First Name:JOFFREE
Middle Name:J
Last Name:BASILISCO
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 S 9TH ST
Mailing Address - Street 2:STE 4
Mailing Address - City:NOBLESVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46060-2631
Mailing Address - Country:US
Mailing Address - Phone:765-524-3946
Mailing Address - Fax:317-708-6496
Practice Address - Street 1:1023 W MAIN ST
Practice Address - Street 2:
Practice Address - City:VEVAY
Practice Address - State:IN
Practice Address - Zip Code:47043-9192
Practice Address - Country:US
Practice Address - Phone:812-427-2803
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-03
Last Update Date:2020-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY003680225100000X
IN05007999A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist