=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790220903
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RAYMOND BALES
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/23/2016
-----------------------------------------------------
Last Update Date | 12/23/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 304 WARDLEY RD
-----------------------------------------------------
City | KNOXVILLE
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37934-1829
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 865-269-4483
-----------------------------------------------------
Fax | 865-288-7974
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 304 WARDLEY RD
-----------------------------------------------------
City | KNOXVILLE
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37934-1829
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 865-269-4483
-----------------------------------------------------
Fax | 865-288-7974
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 372600000X
-----------------------------------------------------
Taxonomy Name | Adult Companion
-----------------------------------------------------
License Number | I000000019088
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------