Healthcare Provider Details

I. General information

NPI: 1912504093
Provider Name (Legal Business Name): DALLAS OMAR MCWILLIAMS IDMT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/02/2020
Last Update Date: 06/15/2022
Certification Date: 06/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 BODIN CIR
FAIRFIELD CA
94535-1809
US

IV. Provider business mailing address

1229 126TH STREET CT E
TACOMA WA
98445-7100
US

V. Phone/Fax

Practice location:
  • Phone: 707-423-3000
  • Fax:
Mailing address:
  • Phone: 253-223-6417
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1710I1003X
TaxonomyIndependent Duty Medical Technicians
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: