1407611478 NPI number — RIKI JO WILLIAMSON

Table of content: RIKI JO WILLIAMSON (NPI 1407611478)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407611478 NPI number — RIKI JO WILLIAMSON

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WILLIAMSON
Provider First Name:
RIKI
Provider Middle Name:
JO
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
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:
1407611478
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/19/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4002 TECHNOLOGY CTR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LONGVIEW
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75605-2697
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
903-247-0484
Provider Business Mailing Address Fax Number:
903-247-0485

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
402 N KAUFMAN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LINDEN
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75563-5234
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
903-756-5581
Provider Business Practice Location Address Fax Number:
903-756-5005
Provider Enumeration Date:
02/19/2024

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: 363LF0000X , with the licence number:  1153075 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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