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General NPI Number Information
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NPI Number | 1073106027
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Entity Type | Organization
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Legal Business Name | GREAT MEDICAL LLC
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Dates
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Enumeration Date | 02/19/2021
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Last Update Date | 02/19/2021
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Provider Practice Location Address
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Address Line | 9591 FOOTHILL BLVD
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City | RANCHO CUCAMONGA
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State | CA
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Zip | 91730-3506
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Country | US
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Telephone | 909-747-4531
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Fax |
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Provider Business Mailing Address
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Address Line | 1508 BARTON RD # 116
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City | REDLANDS
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State | CA
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Zip | 92373-1410
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Country | US
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Telephone | 919-939-5111
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | MR. CHARLES JEROD WILLIAMS JR.
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Credential | REGISTERED NURSE
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Telephone | 919-939-5111
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 261QH0100X
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Taxonomy Name | Health Service Clinic/Center
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License Number |
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License Number State |
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