Healthcare Provider Details

I. General information

NPI: 1518698257
Provider Name (Legal Business Name): MATILDA BATES
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/22/2022
Last Update Date: 02/10/2023
Certification Date: 02/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11111 IRIS CT
CORONA CA
92883-3112
US

IV. Provider business mailing address

11111 IRIS CT
CORONA CA
92883-3112
US

V. Phone/Fax

Practice location:
  • Phone: 918-949-1962
  • Fax:
Mailing address:
  • Phone: 918-949-1962
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License Number95156829
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: