Healthcare Provider Details

I. General information

NPI: 1982689626
Provider Name (Legal Business Name): GREGORY L DALES
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/14/2005
Last Update Date: 04/16/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6065 HIGHWAY 193
GEORGETOWN CA
95634
US

IV. Provider business mailing address

PO BOX 1807
GEORGETOWN CA
95634-1807
US

V. Phone/Fax

Practice location:
  • Phone: 530-333-2555
  • Fax: 530-333-2832
Mailing address:
  • Phone: 530-333-2555
  • Fax: 530-333-2832

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN369163
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberNP6962
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: