Healthcare Provider Details

I. General information

NPI: 1164494860
Provider Name (Legal Business Name): GEORGE JAY WILLIAMS IV A.T.,C
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 02/06/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3001 N BOULEVARD
RICHMOND VA
23230-4331
US

IV. Provider business mailing address

3 BROOKFORD CT
GREENVILLE SC
29615-6108
US

V. Phone/Fax

Practice location:
  • Phone: 804-359-4444
  • Fax:
Mailing address:
  • Phone: 864-275-0289
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number0126000532
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: