1255666590 NPI number — MR. DALE WILLIAM WILLETTS TECHNICIAN

Table of content: MR. DALE WILLIAM WILLETTS TECHNICIAN (NPI 1255666590)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255666590 NPI number — MR. DALE WILLIAM WILLETTS TECHNICIAN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WILLETTS
Provider First Name:
DALE
Provider Middle Name:
WILLIAM
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
TECHNICIAN
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
WILLETTS
Provider Other First Name:
ELIZABETH
Provider Other Middle Name:
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
TECHNICIAN
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1255666590
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3733 RIVERBROOK DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LOUISVILLE
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37777-3159
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
714-914-6180
Provider Business Mailing Address Fax Number:
865-233-7747

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3733 RIVERBROOK DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LOUISVILLE
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37777
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
714-914-6180
Provider Business Practice Location Address Fax Number:
865-233-7747
Provider Enumeration Date:
10/05/2009

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: 246ZX2200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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