Healthcare Provider Details

I. General information

NPI: 1245403666
Provider Name (Legal Business Name): OLIVER DALE BAGLEY D.P.M., INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/07/2008
Last Update Date: 07/06/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1310 CONTINENTAL ST
REDDING CA
96001-0839
US

IV. Provider business mailing address

1310 CONTINENTAL ST
REDDING CA
96001-0839
US

V. Phone/Fax

Practice location:
  • Phone: 530-244-0674
  • Fax: 530-244-1033
Mailing address:
  • Phone: 530-244-0674
  • Fax: 530-244-1033

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberE1237
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code213EP1101X
TaxonomyPrimary Podiatric Medicine Podiatrist
License NumberE1237
License Number StateCA

VIII. Authorized Official

Name: DR. OLIVER D. BAGLEY
Title or Position: OWNER
Credential: D.P.M.
Phone: 530-244-0674