Provider Demographics
NPI:1497825814
Name:WILLIS, LAURA A (DC)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:A
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:PO BOX 1176
Mailing Address - Street 2:
Mailing Address - City:CARDIFF
Mailing Address - State:CA
Mailing Address - Zip Code:92007-7176
Mailing Address - Country:US
Mailing Address - Phone:760-436-7999
Mailing Address - Fax:760-436-3993
Practice Address - Street 1:40 W COCHRAN ST STE 104
Practice Address - Street 2:
Practice Address - City:SIMI VALLEY
Practice Address - State:CA
Practice Address - Zip Code:93065-6245
Practice Address - Country:US
Practice Address - Phone:760-436-7999
Practice Address - Fax:760-436-3993
Is Sole Proprietor?:No
Enumeration Date:2006-11-09
Last Update Date:2017-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC19937111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
U19302Medicare UPIN