Provider Demographics
NPI:1083169577
Name:FERNANDEZ-WILLS LLC
Entity Type:Organization
Organization Name:FERNANDEZ-WILLS LLC
Other - Org Name:FULL LIFE CHIROPRACTIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JUAN
Authorized Official - Middle Name:
Authorized Official - Last Name:FERNANDEZ-GOMEZ
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:570-239-6961
Mailing Address - Street 1:1741 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:OH
Mailing Address - Zip Code:45373-2301
Mailing Address - Country:US
Mailing Address - Phone:937-552-7364
Mailing Address - Fax:
Practice Address - Street 1:1741 W MAIN ST
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:OH
Practice Address - Zip Code:45373-2301
Practice Address - Country:US
Practice Address - Phone:937-552-7364
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-24
Last Update Date:2016-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH4584111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty