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General NPI Number Information
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NPI Number | 1053775692
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Entity Type | Individual
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Provider Name | ROXENE BATES LAC, DIPL OM
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Gender | Female
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Dates
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Enumeration Date | 04/10/2016
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Last Update Date | 04/10/2016
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Provider Practice Location Address
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Address Line | 19 S MAIN ST
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City | PROVIDENCE
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State | UT
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Zip | 84332-9786
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Country | US
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Telephone | 818-519-5083
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 1
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City | PROVIDENCE
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State | UT
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Zip | 84332-0001
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Country | US
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Telephone | 818-519-5083
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 171100000X
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Taxonomy Name | Acupuncturist
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License Number | 9654360-1201
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License Number State | UT
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