Provider Demographics
NPI:1871688242
Name:BATES, LISA RAE (D C)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:RAE
Last Name:BATES
Suffix:
Gender:F
Credentials:D C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:621 EUCLID AVENUE
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50313
Mailing Address - Country:US
Mailing Address - Phone:515-282-8141
Mailing Address - Fax:515-282-8670
Practice Address - Street 1:621 EUCLID AVENUE
Practice Address - Street 2:
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50313
Practice Address - Country:US
Practice Address - Phone:515-282-8141
Practice Address - Fax:515-282-8670
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA06751111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA38384OtherWELLMARK BC-BS
IA0464834Medicaid
IA38384OtherWELLMARK BC-BS
IAV03959Medicare UPIN