Healthcare Provider Details

I. General information

NPI: 1871188078
Provider Name (Legal Business Name): JUSTIN WILLIAMS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/09/2021
Last Update Date: 03/09/2021
Certification Date: 03/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17309 REDWOOD AVE
SOUTHFIELD MI
48076-2866
US

IV. Provider business mailing address

3400 E SOUTHERN AVE APT 162
PHOENIX AZ
85040-3890
US

V. Phone/Fax

Practice location:
  • Phone: 623-755-3841
  • Fax:
Mailing address:
  • Phone: 623-755-3841
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: