Provider Demographics
NPI:1740518711
Name:BALES, GLADWYNE SUELLO
Entity type:Individual
Prefix:MR
First Name:GLADWYNE
Middle Name:SUELLO
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 1:1324 RENISON LN
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:CA
Mailing Address - Zip Code:95648-3219
Mailing Address - Country:US
Mailing Address - Phone:916-832-4660
Mailing Address - Fax:916-543-4946
Practice Address - Street 1:1324 RENISON LN
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:CA
Practice Address - Zip Code:95648-3219
Practice Address - Country:US
Practice Address - Phone:916-832-4660
Practice Address - Fax:916-543-4946
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-02
Last Update Date:2009-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA99789343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)