Provider Demographics
NPI:1295706117
Name:BASS, CHARLES EDWARD JR (RPT)
Entity type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:EDWARD
Last Name:BASS
Suffix:JR
Gender:M
Credentials:RPT
Other - Prefix:
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Mailing Address - Street 1:PO BOX 883
Mailing Address - Street 2:
Mailing Address - City:DUBLIN
Mailing Address - State:GA
Mailing Address - Zip Code:31040-0883
Mailing Address - Country:US
Mailing Address - Phone:478-272-7494
Mailing Address - Fax:478-272-2616
Practice Address - Street 1:101 FAIRVIEW PARK DR
Practice Address - Street 2:
Practice Address - City:DUBLIN
Practice Address - State:GA
Practice Address - Zip Code:31021-2501
Practice Address - Country:US
Practice Address - Phone:478-272-7494
Practice Address - Fax:478-272-2616
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-30
Last Update Date:2023-06-29
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA1787225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000562504CMedicaid
GA000562594FMedicaid