MEDICARE: RODERICK SHAUN WILLIAMS LAT

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	2255A2300X	Athletic Trainer	AT4955	TX

General Provider Information

NPI Number	:	1609298579
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RODERICK SHAUN WILLIAMS LAT

Provider Business Mailing Address
First Line	:	19100 NORTHPOINTE RIDGE LN
Second Line	:
City	:	TOMBALL
State	:	TX
Zip	:	77377-5889
Country	:	US
Telephone Number	:	281-352-3230
Fax Number	:

Provider Business Practice Location Address
First Line	:	19100 NORTHPOINTE RIDGE LN
Second Line	:
City	:	TOMBALL
State	:	TX
Zip	:	77377-5889
Country	:	US
Telephone Number	:	281-352-3230
Fax Number	:

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

Provider Enumeration Date	:	01/13/2014
Last Update Date	:	01/13/2014

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