Provider Demographics
NPI:1720362809
Name:WILLSON, TIMOTHY R (DC)
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:R
Last Name:WILLSON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4118C FRANKLIN RD SW
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24014-5266
Mailing Address - Country:US
Mailing Address - Phone:540-488-2557
Mailing Address - Fax:
Practice Address - Street 1:4118C FRANKLIN RD SW
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24014-5266
Practice Address - Country:US
Practice Address - Phone:540-488-2557
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-06
Last Update Date:2011-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0104556880111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor