Healthcare Provider Details

I. General information

NPI: 1215601190
Provider Name (Legal Business Name): ADAM LEE WILLIAMS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/04/2021
Last Update Date: 08/04/2021
Certification Date: 08/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4105 W JEFFERSON BLVD STE 2
FORT WAYNE IN
46804-6890
US

IV. Provider business mailing address

2904 WAYNEWOOD DR
FORT WAYNE IN
46809-2629
US

V. Phone/Fax

Practice location:
  • Phone: 260-610-6133
  • Fax:
Mailing address:
  • Phone: 260-467-9829
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License Number17001434A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: