Provider Demographics
NPI:1255484713
Name:WILLIS CHIROPRACTIC OFFICES
Entity Type:Organization
Organization Name:WILLIS CHIROPRACTIC OFFICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:C
Authorized Official - Last Name:WILLIS
Authorized Official - Suffix:
Authorized Official - Credentials:CH
Authorized Official - Phone:276-963-0395
Mailing Address - Street 1:PO BOX 1045
Mailing Address - Street 2:
Mailing Address - City:RICHLANDS
Mailing Address - State:VA
Mailing Address - Zip Code:24641-1045
Mailing Address - Country:US
Mailing Address - Phone:276-963-0395
Mailing Address - Fax:276-964-2225
Practice Address - Street 1:305 ALLEGHENY ST
Practice Address - Street 2:
Practice Address - City:RICHLANDS
Practice Address - State:VA
Practice Address - Zip Code:24641-2346
Practice Address - Country:US
Practice Address - Phone:276-963-0395
Practice Address - Fax:276-964-2225
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-19
Last Update Date:2007-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0104000181111N00000X
VA0104556270111N00000X
VA0104556501111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA4669783OtherAETNA
VA145963OtherANTHEM BLUE CROSS BLUE SH
VA007315OtherANTHEM BLUE CROSS BLUE SH
VA1300519OtherUNITED MINE WORKERS UMWA
VA7880576OtherAETNA
VA005429W98Medicare ID - Type UnspecifiedDR BRENT O WARNER
VA007315OtherANTHEM BLUE CROSS BLUE SH