=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720477995
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RICHARD JUSTIN BATES NP-C
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/12/2015
-----------------------------------------------------
Last Update Date | 10/15/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2708 HIGHWAY 78 E
-----------------------------------------------------
City | JASPER
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 35501-3430
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 205-387-2253
-----------------------------------------------------
Fax | 205-387-2269
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2708 HIGHWAY 78 E
-----------------------------------------------------
City | JASPER
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 35501-3430
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 205-387-2253
-----------------------------------------------------
Fax | 205-387-2269
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 1-117933
-----------------------------------------------------
License Number State | AL
-----------------------------------------------------