Healthcare Provider Details

I. General information

NPI: 1306591227
Provider Name (Legal Business Name): SANDREKA MAE WILLIAMS COSMETOLOGIST
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MS. SANDREKA MAE WILLIAMS

II. Dates (important events)

Enumeration Date: 02/18/2022
Last Update Date: 02/18/2022
Certification Date: 01/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3832 PIEDMONT AVE
OAKLAND CA
94611-5354
US

IV. Provider business mailing address

3832 PIEDMONT AVE # 106
OAKLAND CA
94611-5354
US

V. Phone/Fax

Practice location:
  • Phone: 510-734-6658
  • Fax:
Mailing address:
  • Phone: 510-734-6658
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License NumberKK270941
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: