Provider Demographics
NPI:1003334152
Name:WILLIAMS, RANDAL REGINALD
Entity Type:Individual
Prefix:
First Name:RANDAL
Middle Name:REGINALD
Last Name:WILLIAMS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 FLAGSTONE APT 843
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92606-7684
Mailing Address - Country:US
Mailing Address - Phone:949-300-6415
Mailing Address - Fax:
Practice Address - Street 1:26137 LA PAZ RD STE 230
Practice Address - Street 2:
Practice Address - City:MISSION VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92691-5337
Practice Address - Country:US
Practice Address - Phone:949-595-8610
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-08
Last Update Date:2017-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No171W00000XOther Service ProvidersContractor