Provider Demographics
NPI:1982234878
Name:YATES, ROOSEVELT JR
Entity type:Individual
Prefix:
First Name:ROOSEVELT
Middle Name:
Last Name:YATES
Suffix:JR
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 1:13848 ALMETZ ST
Mailing Address - Street 2:
Mailing Address - City:SYLMAR
Mailing Address - State:CA
Mailing Address - Zip Code:91342-1730
Mailing Address - Country:US
Mailing Address - Phone:818-403-6533
Mailing Address - Fax:
Practice Address - Street 1:13848 ALMETZ ST
Practice Address - Street 2:
Practice Address - City:SYLMAR
Practice Address - State:CA
Practice Address - Zip Code:91342-1730
Practice Address - Country:US
Practice Address - Phone:818-403-6533
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-21
Last Update Date:2020-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAF7584255172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver