Provider Demographics
NPI:1790220903
Name:BALES, RAYMOND
Entity Type:Individual
Prefix:
First Name:RAYMOND
Middle Name:
Last Name:BALES
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 1:304 WARDLEY RD
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37934-1829
Mailing Address - Country:US
Mailing Address - Phone:865-269-4483
Mailing Address - Fax:865-288-7974
Practice Address - Street 1:304 WARDLEY RD
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37934-1829
Practice Address - Country:US
Practice Address - Phone:865-269-4483
Practice Address - Fax:865-288-7974
Is Sole Proprietor?:No
Enumeration Date:2016-12-23
Last Update Date:2016-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNI000000019088372600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes372600000XNursing Service Related ProvidersAdult Companion
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNI000000019088OtherNON-MEDICAL IN HOME CARE AGENCY