Provider Demographics
NPI:1801936869
Name:BASS, RICHARD ERWIN (DC)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:ERWIN
Last Name:BASS
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:695 JIM ROSS RD
Mailing Address - Street 2:
Mailing Address - City:EASTMAN
Mailing Address - State:GA
Mailing Address - Zip Code:31023-8433
Mailing Address - Country:US
Mailing Address - Phone:478-374-4604
Mailing Address - Fax:
Practice Address - Street 1:507 E OAK ST
Practice Address - Street 2:
Practice Address - City:MC RAE
Practice Address - State:GA
Practice Address - Zip Code:31055-1637
Practice Address - Country:US
Practice Address - Phone:229-868-9899
Practice Address - Fax:229-868-2890
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA6990111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAU17832Medicare UPIN
GA35ZCJGNMedicare ID - Type Unspecified