Provider Demographics
NPI:1245975614
Name:BASSO FAMILY LLC
Entity type:Organization
Organization Name:BASSO FAMILY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:KIPP
Authorized Official - Last Name:BASSO
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:618-578-8667
Mailing Address - Street 1:4105 ENDICOTT CT
Mailing Address - Street 2:
Mailing Address - City:SWANSEA
Mailing Address - State:IL
Mailing Address - Zip Code:62226-8210
Mailing Address - Country:US
Mailing Address - Phone:618-578-8667
Mailing Address - Fax:
Practice Address - Street 1:2821 N BALLAS RD STE C15
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63131-2300
Practice Address - Country:US
Practice Address - Phone:314-394-8580
Practice Address - Fax:314-983-9650
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-04-30
Last Update Date:2023-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty