Basic Information
| Provider Information | |||||||||
| NPI: | 1497300628 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BASSO-WILLIAMS 11 BLADE OF CALIFORNIA, PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5118 E WINDSTONE TRL | ||||||||
| Address2: | |||||||||
| City: | CAVE CREEK | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853312907 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 207 W LEGION RD | ||||||||
| Address2: | |||||||||
| City: | BRAWLEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 922277780 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7603513333 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/05/2019 | ||||||||
| LastUpdateDate: | 04/10/2020 | ||||||||
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| AuthorizedOfficialLastName: | BASSO-WILLIAMS | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 6238567553 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | DO | ||||||||
| NPICertificationDate: | 04/10/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 1316200967 | 05 | CA | MEDICAID |