Provider Demographics
NPI:1134633753
Name:BASA, ERNESTO JR
Entity type:Individual
Prefix:
First Name:ERNESTO
Middle Name:
Last Name:BASA
Suffix:JR
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 1:11740 LOISDALE WAY
Mailing Address - Street 2:
Mailing Address - City:RANCHO CORDOVA
Mailing Address - State:CA
Mailing Address - Zip Code:95742-8028
Mailing Address - Country:US
Mailing Address - Phone:916-402-5126
Mailing Address - Fax:
Practice Address - Street 1:11740 LOISDALE WAY
Practice Address - Street 2:
Practice Address - City:RANCHO CORDOVA
Practice Address - State:CA
Practice Address - Zip Code:95742-8028
Practice Address - Country:US
Practice Address - Phone:916-402-5126
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-17
Last Update Date:2017-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician