Healthcare Provider Details

I. General information

NPI: 1922920289
Provider Name (Legal Business Name): CHARLES WILLIAMS JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/28/2026
Last Update Date: 07/28/2026
Certification Date: 07/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

29648 PHILLIPS AVE
WICKLIFFE OH
44092-2210
US

IV. Provider business mailing address

3081 EAST 40TH
CLEVELAND OH
44103
US

V. Phone/Fax

Practice location:
  • Phone: 216-256-6883
  • Fax:
Mailing address:
  • Phone: 216-260-1388
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: