Healthcare Provider Details

I. General information

NPI: 1083202279
Provider Name (Legal Business Name): MR. SYLVESTER L WILLIAMS II
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/04/2021
Last Update Date: 01/04/2021
Certification Date: 01/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

550 S VERMONT AVE
LOS ANGELES CA
90020-1912
US

IV. Provider business mailing address

15500 MIDTOWN DR APT 116
VICTORVILLE CA
92394-2145
US

V. Phone/Fax

Practice location:
  • Phone: 323-470-0472
  • Fax:
Mailing address:
  • Phone: 323-470-0472
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code167G00000X
TaxonomyLicensed Psychiatric Technician
License Number40588
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: