Provider Demographics
NPI:1073106027
Name:GREAT MEDICAL LLC
Entity Type:Organization
Organization Name:GREAT MEDICAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:JEROD
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:JR
Authorized Official - Credentials:REGISTERED NURSE
Authorized Official - Phone:919-939-5111
Mailing Address - Street 1:1508 BARTON RD # 116
Mailing Address - Street 2:
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92373-1410
Mailing Address - Country:US
Mailing Address - Phone:919-939-5111
Mailing Address - Fax:
Practice Address - Street 1:9591 FOOTHILL BLVD
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-3506
Practice Address - Country:US
Practice Address - Phone:909-747-4531
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-02-19
Last Update Date:2021-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center