Provider Demographics
NPI:1669778742
Name:BATES, MAVIS A (L AC)
Entity type:Individual
Prefix:MS
First Name:MAVIS
Middle Name:A
Last Name:BATES
Suffix:
Gender:F
Credentials:L AC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:412 N LAKE ST
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:IL
Mailing Address - Zip Code:60506-4106
Mailing Address - Country:US
Mailing Address - Phone:630-605-9244
Mailing Address - Fax:630-892-2535
Practice Address - Street 1:412 N LAKE ST
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:IL
Practice Address - Zip Code:60506-4106
Practice Address - Country:US
Practice Address - Phone:630-605-9244
Practice Address - Fax:630-892-2535
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-07
Last Update Date:2011-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL198-000596171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist