Provider Demographics
NPI:1720236896
Name:BASE, JOHN CARLO SHUN (OTR)
Entity Type:Individual
Prefix:
First Name:JOHN CARLO
Middle Name:SHUN
Last Name:BASE
Suffix:
Gender:M
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:150 KLATTENHOFF LN
Mailing Address - Street 2:APT 2104
Mailing Address - City:HUTTO
Mailing Address - State:TX
Mailing Address - Zip Code:78634-4601
Mailing Address - Country:US
Mailing Address - Phone:512-987-8718
Mailing Address - Fax:
Practice Address - Street 1:359 VILLAGE COMMONS BLVD
Practice Address - Street 2:
Practice Address - City:GEORGETOWN
Practice Address - State:TX
Practice Address - Zip Code:78633-4448
Practice Address - Country:US
Practice Address - Phone:512-277-6405
Practice Address - Fax:512-277-6406
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-03
Last Update Date:2017-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX117013225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist