Basic Information
| Provider Information | |||||||||
| NPI: | 1235682808 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BATES | ||||||||
| FirstName: | DAKOTA | ||||||||
| MiddleName: | BLUE | ||||||||
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| Credential: | MSW INTERN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 16575 MALLORY DR | ||||||||
| Address2: | |||||||||
| City: | FONTANA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923356610 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9095596895 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1556 S SULTANA AVE | ||||||||
| Address2: | |||||||||
| City: | ONTARIO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917614238 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9094186923 | ||||||||
| FaxNumber: | 9094186937 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/29/2016 | ||||||||
| LastUpdateDate: | 07/29/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.