Healthcare Provider Details

I. General information

NPI: 1134594369
Provider Name (Legal Business Name): MR. REGINALD LAMONT WILLIAMSON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/14/2015
Last Update Date: 12/14/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12923 S PARNELL AVE
CHICAGO IL
60628-7442
US

IV. Provider business mailing address

12923 S PARNELL AVE
CHICAGO IL
60628-7442
US

V. Phone/Fax

Practice location:
  • Phone: 773-405-8996
  • Fax: 773-468-7918
Mailing address:
  • Phone: 773-405-8996
  • Fax: 773-468-7918

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172A00000X
TaxonomyDriver
License NumberW45273274015
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: