Provider Demographics
NPI:1467045542
Name:BATES, EDWARD J
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:J
Last Name:BATES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:SAM
Other - Middle Name:
Other - Last Name:KABBANI
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1138 S CRESCENT HEIGHTS BLVD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90035-2635
Mailing Address - Country:US
Mailing Address - Phone:310-658-4008
Mailing Address - Fax:
Practice Address - Street 1:1138 S CRESCENT HEIGHTS BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90035-2635
Practice Address - Country:US
Practice Address - Phone:310-658-4008
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-18
Last Update Date:2021-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA332900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332900000XSuppliersNon-Pharmacy Dispensing Site