Healthcare Provider Details

I. General information

NPI: 1144824517
Provider Name (Legal Business Name): CAROLYN DELORES BATES
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/25/2020
Last Update Date: 11/25/2020
Certification Date: 11/25/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9124 S WESTERN AVE
LOS ANGELES CA
90047-3518
US

IV. Provider business mailing address

9124 S WESTERN AVE
LOS ANGELES CA
90047-3518
US

V. Phone/Fax

Practice location:
  • Phone: 213-325-2348
  • Fax:
Mailing address:
  • Phone: 213-325-2348
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License Number5733
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code164X00000X
TaxonomyLicensed Vocational Nurse
License Number705588
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: