Provider Demographics
NPI:1235436619
Name:WILLIS CHIRO MED-MB, INC.
Entity Type:Organization
Organization Name:WILLIS CHIRO MED-MB, INC.
Other - Org Name:WILLIS CHIRO MED-MB, INC.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:
Authorized Official - Last Name:WILLIS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:843-626-6666
Mailing Address - Street 1:2105 CROMLEY CIR STE B
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29577-3168
Mailing Address - Country:US
Mailing Address - Phone:843-626-6666
Mailing Address - Fax:888-456-9396
Practice Address - Street 1:2105 CROMLEY CIR STE B
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29577-3168
Practice Address - Country:US
Practice Address - Phone:843-626-6666
Practice Address - Fax:888-456-9396
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WILLIS CHIRO MED-MB, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-02-20
Last Update Date:2011-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC997111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC5316OtherMEDICARE PTAN
SC285285Medicaid