Provider Demographics
NPI:1295466621
Name:BASLEY, ALTAEVIST
Entity Type:Individual
Prefix:
First Name:ALTAEVIST
Middle Name:
Last Name:BASLEY
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 1:3235 BALLS CHURCH RD
Mailing Address - Street 2:
Mailing Address - City:JEFFERSONVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31044-2105
Mailing Address - Country:US
Mailing Address - Phone:478-233-5118
Mailing Address - Fax:
Practice Address - Street 1:3235 BALLS CHURCH RD
Practice Address - Street 2:
Practice Address - City:JEFFERSONVILLE
Practice Address - State:GA
Practice Address - Zip Code:31044-2105
Practice Address - Country:US
Practice Address - Phone:478-233-5118
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-17
Last Update Date:2022-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer