Provider Demographics
NPI:1710974779
Name:J R WILLIS DC PC
Entity Type:Organization
Organization Name:J R WILLIS DC PC
Other - Org Name:WILLIS CHIROPRACTIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:
Authorized Official - First Name:LEE
Authorized Official - Middle Name:R
Authorized Official - Last Name:WILLIS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:276-228-3883
Mailing Address - Street 1:570 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WYTHEVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24382-2033
Mailing Address - Country:US
Mailing Address - Phone:276-228-3883
Mailing Address - Fax:276-223-1357
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:2005-10-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV589111N00000X
VA0104001278111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0131755000Medicaid
T21472Medicare UPIN
WVWI0719381Medicare ID - Type Unspecified