Provider Demographics
NPI:1609886134
Name:WILLIAMS, WAITES EARL JR (DC)
Entity Type:Individual
Prefix:MR
First Name:WAITES
Middle Name:EARL
Last Name:WILLIAMS
Suffix:JR
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:POST OFFICE BOX 3176
Mailing Address - Street 2:
Mailing Address - City:SAN DIMAS
Mailing Address - State:CA
Mailing Address - Zip Code:91773
Mailing Address - Country:US
Mailing Address - Phone:909-592-2823
Mailing Address - Fax:909-394-7825
Practice Address - Street 1:615 EAST FOOTHILL BLVD
Practice Address - Street 2:SUITE D
Practice Address - City:SAN DIMAS
Practice Address - State:CA
Practice Address - Zip Code:91773
Practice Address - Country:US
Practice Address - Phone:909-592-2823
Practice Address - Fax:909-394-7825
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-08
Last Update Date:2009-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA16160111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor