Provider Demographics
NPI:1073955639
Name:BASS, GLENDAIL
Entity Type:Individual
Prefix:
First Name:GLENDAIL
Middle Name:
Last Name:BASS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2909 HAYLING DR
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27610-5268
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:839 WILKESBORO BLVD NE
Practice Address - Street 2:
Practice Address - City:LENOIR
Practice Address - State:NC
Practice Address - Zip Code:28645-4612
Practice Address - Country:US
Practice Address - Phone:828-759-2228
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-24
Last Update Date:2013-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker