=====================================================
General NPI Number Information
=====================================================
NPI Number | 1912499773
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MR. JAMES A GATES
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/06/2018
-----------------------------------------------------
Last Update Date | 06/06/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 71 E MAIN ST
-----------------------------------------------------
City | BOGOTA
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07603-1307
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 845-536-1234
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10 BROADWAY
-----------------------------------------------------
City | PIERMONT
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10968-1125
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 845-536-1234
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number | 18KT00771300
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------