MEDICARE: BRANDY R WILLIAMS IDMT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1710I1003X	Independent Duty Medical Technicians

General Provider Information

NPI Number	:	1346483500
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRANDY R WILLIAMS IDMT

Provider Business Mailing Address
First Line	:	9303 GILCREASE AVE
Second Line	:	UNIT 1207
City	:	LAS VEGAS
State	:	NV
Zip	:	89149-0199
Country	:	US
Telephone Number	:	702-408-8360
Fax Number	:

Provider Business Practice Location Address
First Line	:	9303 GILCREASE AVE
Second Line	:	UNIT 1207
City	:	LAS VEGAS
State	:	NV
Zip	:	89149-0199
Country	:	US
Telephone Number	:	702-404-1142
Fax Number	:	702-404-0425

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/16/2009
Last Update Date	:	04/16/2009

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