Healthcare Provider Details

I. General information

NPI: 1952817090
Provider Name (Legal Business Name): PRINCE WILLIAMS ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/27/2017
Last Update Date: 12/27/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 CAMPUS CTR
SEASIDE CA
93955-8000
US

IV. Provider business mailing address

1108 JACKSON CT
MARINA CA
93933-5032
US

V. Phone/Fax

Practice location:
  • Phone: 831-582-3010
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number060502048
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: