Provider Demographics
NPI:1558816983
Name:BATES, KEN
Entity Type:Individual
Prefix:
First Name:KEN
Middle Name:
Last Name:BATES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1656 E 12TH ST
Mailing Address - Street 2:
Mailing Address - City:CASPER
Mailing Address - State:WY
Mailing Address - Zip Code:82601-4004
Mailing Address - Country:US
Mailing Address - Phone:307-265-1007
Mailing Address - Fax:307-577-5716
Practice Address - Street 1:1656 E 12TH ST
Practice Address - Street 2:
Practice Address - City:CASPER
Practice Address - State:WY
Practice Address - Zip Code:82601-4004
Practice Address - Country:US
Practice Address - Phone:307-265-1007
Practice Address - Fax:307-577-5716
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-15
Last Update Date:2016-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator