Provider Demographics
NPI:1124408786
Name:BASS, YARDELL TAVARIUS
Entity Type:Individual
Prefix:
First Name:YARDELL
Middle Name:TAVARIUS
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 1:4042 MEADOWGLEN AVE
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89121-6344
Mailing Address - Country:US
Mailing Address - Phone:702-287-8459
Mailing Address - Fax:
Practice Address - Street 1:2020 W BONANZA RD
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89106-4710
Practice Address - Country:US
Practice Address - Phone:702-749-6332
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-08
Last Update Date:2015-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner