Provider Demographics
NPI:1841439551
Name:BASCO, RUSEL DAVID (DPT)
Entity type:Individual
Prefix:
First Name:RUSEL
Middle Name:DAVID
Last Name:BASCO
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4329 VAN NUYS BLVD APT 3
Mailing Address - Street 2:
Mailing Address - City:SHERMAN OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91403-3725
Mailing Address - Country:US
Mailing Address - Phone:818-634-0626
Mailing Address - Fax:
Practice Address - Street 1:4329 VAN NUYS BLVD APT 3
Practice Address - Street 2:
Practice Address - City:SHERMAN OAKS
Practice Address - State:CA
Practice Address - Zip Code:91403-3725
Practice Address - Country:US
Practice Address - Phone:818-634-0626
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-02-19
Last Update Date:2011-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA24930225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist