=====================================================
General NPI Number Information
=====================================================
NPI Number | 1780034561
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | J WILLIAMS ENT, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/13/2016
-----------------------------------------------------
Last Update Date | 06/13/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9120 NE VANCOUVER MALL LOOP SUITE 240
-----------------------------------------------------
City | VANCOUVER
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98662-6353
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-253-6028
-----------------------------------------------------
Fax | 360-253-6029
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9120 NE VANCOUVER MALL LOOP SUITE 240
-----------------------------------------------------
City | VANCOUVER
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98662-6353
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-253-6028
-----------------------------------------------------
Fax | 360-253-6029
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | FRANCHISE OWNER
-----------------------------------------------------
Name | MS. JULIE ANNE WILLIAMS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 360-253-6028
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 253Z00000X
-----------------------------------------------------
Taxonomy Name | In Home Supportive Care Agency
-----------------------------------------------------
License Number | IHS.FS.00000031
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------