Provider Demographics
NPI:1861586307
Name:BASILA, GREGORY EDWARD (RD)
Entity type:Individual
Prefix:MR
First Name:GREGORY
Middle Name:EDWARD
Last Name:BASILA
Suffix:
Gender:M
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2615 E. CLINTON AVENUE
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93703-2286
Mailing Address - Country:US
Mailing Address - Phone:559-225-6100
Mailing Address - Fax:559-241-6483
Practice Address - Street 1:2615 E. CLINTON AVENUE
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93703-2286
Practice Address - Country:US
Practice Address - Phone:559-225-6100
Practice Address - Fax:559-241-6483
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
724514133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered