Provider Demographics
NPI:1497300628
Name:BASSO-WILLIAMS 11 BLADE OF CALIFORNIA, PC
Entity Type:Organization
Organization Name:BASSO-WILLIAMS 11 BLADE OF CALIFORNIA, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:BASSO-WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:209-956-7732
Mailing Address - Street 1:PO BOX 840027
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90084-0027
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:207 W LEGION RD
Practice Address - Street 2:
Practice Address - City:BRAWLEY
Practice Address - State:CA
Practice Address - Zip Code:92227-7780
Practice Address - Country:US
Practice Address - Phone:760-351-3333
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-08-05
Last Update Date:2024-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1316200967Medicaid