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General NPI Number Information
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NPI Number | 1134594369
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Entity Type | Individual
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Provider Name | MR. REGINALD LAMONT WILLIAMSON
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Gender | Male
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Dates
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Enumeration Date | 12/14/2015
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Last Update Date | 12/14/2015
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Provider Practice Location Address
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Address Line | 12923 S PARNELL AVE
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City | CHICAGO
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State | IL
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Zip | 60628-7442
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Country | US
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Telephone | 773-405-8996
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Fax | 773-468-7918
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Provider Business Mailing Address
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Address Line | 12923 S PARNELL AVE
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City | CHICAGO
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State | IL
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Zip | 60628-7442
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Country | US
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Telephone | 773-405-8996
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Fax | 773-468-7918
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 172A00000X
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Taxonomy Name | Driver
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License Number | W45273274015
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License Number State | IL
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