MEDICARE: MR. LARRY D WILLIAMS C.C.D.C.

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	302R00000X	Health Maintenance Organization

General Provider Information

NPI Number	:	1629101860
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. LARRY D WILLIAMS C.C.D.C.

Provider Business Mailing Address
First Line	:	3453 GAVIOTA AVE
Second Line	:
City	:	LONG BEACH
State	:	CA
Zip	:	90807-4919
Country	:	US
Telephone Number	:	562-355-1800
Fax Number	:

Provider Business Practice Location Address
First Line	:	3453 GAVIOTA AVE
Second Line	:
City	:	LONG BEACH
State	:	CA
Zip	:	90807-4919
Country	:	US
Telephone Number	:	562-355-1800
Fax Number	:

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

Provider Enumeration Date	:	03/14/2007
Last Update Date	:	07/08/2007

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