Healthcare Provider Details

I. General information

NPI: 1073896825
Provider Name (Legal Business Name): KHRYS GATES OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/27/2011
Last Update Date: 05/09/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

HWY 264 MILE POST 388
POLACCA AZ
86042-4000
US

IV. Provider business mailing address

PO BOX 4000
POLACCA AZ
86042-4000
US

V. Phone/Fax

Practice location:
  • Phone: 928-737-6003
  • Fax: 928-737-6080
Mailing address:
  • Phone: 928-737-6003
  • Fax: 928-737-6080

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2845
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: