Provider Demographics
NPI:1518062710
Name:WILLARD CHIROPRACTIC LLC
Entity Type:Organization
Organization Name:WILLARD CHIROPRACTIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CHIROPRACTOR
Authorized Official - Prefix:
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:BRUCE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:417-742-2617
Mailing Address - Street 1:128 GRAND PRAIRIE
Mailing Address - Street 2:P.O. BOX 305
Mailing Address - City:WILLARD
Mailing Address - State:MO
Mailing Address - Zip Code:65781
Mailing Address - Country:US
Mailing Address - Phone:417-742-2617
Mailing Address - Fax:417-742-6887
Practice Address - Street 1:128 GRAND PRAIRIE
Practice Address - Street 2:
Practice Address - City:WILLARD
Practice Address - State:MO
Practice Address - Zip Code:65781
Practice Address - Country:US
Practice Address - Phone:417-742-2617
Practice Address - Fax:417-742-6887
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-13
Last Update Date:2021-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO003562111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO000014919Medicare ID - Type Unspecified
MO001014919Medicare ID - Type Unspecified