Provider Demographics
NPI:1699846394
Name:J. R. WILLIS, D.C., P.C.
Entity Type:Organization
Organization Name:J. R. WILLIS, D.C., P.C.
Other - Org Name:WILLIS CHIROPRACTIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WENDY
Authorized Official - Middle Name:HOLDEN
Authorized Official - Last Name:WILLIS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:304-487-8985
Mailing Address - Street 1:1512 N WALKER ST
Mailing Address - Street 2:
Mailing Address - City:PRINCETON
Mailing Address - State:WV
Mailing Address - Zip Code:24740-2639
Mailing Address - Country:US
Mailing Address - Phone:304-487-8985
Mailing Address - Fax:304-425-1680
Practice Address - Street 1:1512 N WALKER ST
Practice Address - Street 2:
Practice Address - City:PRINCETON
Practice Address - State:WV
Practice Address - Zip Code:24740-2639
Practice Address - Country:US
Practice Address - Phone:304-487-8985
Practice Address - Fax:304-425-1680
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV9238281Medicare ID - Type Unspecified