Provider Demographics
NPI:1497814305
Name:J BASS LTD
Entity Type:Organization
Organization Name:J BASS LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:TINA
Authorized Official - Middle Name:
Authorized Official - Last Name:TEPOVICH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-244-0508
Mailing Address - Street 1:112 S 42ND STREET
Mailing Address - Street 2:
Mailing Address - City:MT. VERNON
Mailing Address - State:IL
Mailing Address - Zip Code:62864
Mailing Address - Country:US
Mailing Address - Phone:618-244-0508
Mailing Address - Fax:618-244-0646
Practice Address - Street 1:112 S 42ND STREET
Practice Address - Street 2:
Practice Address - City:MT. VERNON
Practice Address - State:IL
Practice Address - Zip Code:62864
Practice Address - Country:US
Practice Address - Phone:618-244-0508
Practice Address - Fax:618-244-0646
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-06
Last Update Date:2011-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1922009950OtherBCBS
ILDE6294OtherRR MEDICARE
IL1922009950OtherBCBS