Provider Demographics
NPI:1295843894
Name:WILLIS, MYNDIE (DC)
Entity Type:Individual
Prefix:DR
First Name:MYNDIE
Middle Name:
Last Name:WILLIS
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4916 KNICKERBOCKER RD
Mailing Address - Street 2:
Mailing Address - City:SAN ANGELO
Mailing Address - State:TX
Mailing Address - Zip Code:76904-7517
Mailing Address - Country:US
Mailing Address - Phone:325-949-1112
Mailing Address - Fax:325-949-5551
Practice Address - Street 1:4916 KNICKERBOCKER RD
Practice Address - Street 2:
Practice Address - City:SAN ANGELO
Practice Address - State:TX
Practice Address - Zip Code:76904-7517
Practice Address - Country:US
Practice Address - Phone:325-949-1112
Practice Address - Fax:325-949-5551
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX6027111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXU40807Medicare UPIN
TX603857Medicare ID - Type Unspecified