1114013026 NPI number — MARY BLACK-WILLIAMS NP

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114013026 NPI number — MARY BLACK-WILLIAMS NP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BLACK-WILLIAMS
Provider First Name:
MARY
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
NP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1114013026
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3050 E AIRPORT WAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LONG BEACH
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90806-2404
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
562-432-6966
Provider Business Mailing Address Fax Number:
562-426-4227

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5050 SAN BERNARDINO ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MONTCLAIR
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91763-2326
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
909-626-2463
Provider Business Practice Location Address Fax Number:
909-624-6297
Provider Enumeration Date:
10/05/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LW0102X , with the licence number:  231324 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: RN2313240 . This is a "MEDI-CAL" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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