Provider Demographics
NPI:1114191137
Name:WILLIS FAMILY CHIROPRACTIC, LLC
Entity Type:Organization
Organization Name:WILLIS FAMILY CHIROPRACTIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR, OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:
Authorized Official - Last Name:WILLIS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:208-322-4114
Mailing Address - Street 1:10451 W GARVERDALE CT
Mailing Address - Street 2:SUITE 201
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-5408
Mailing Address - Country:US
Mailing Address - Phone:208-322-4114
Mailing Address - Fax:208-322-4115
Practice Address - Street 1:10451 W GARVERDALE CT
Practice Address - Street 2:SUITE 201
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-5408
Practice Address - Country:US
Practice Address - Phone:208-322-4114
Practice Address - Fax:208-322-4115
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-22
Last Update Date:2008-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDCHIA-1268, CHIA-1267111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty