Provider Demographics
NPI:1922141456
Name:TILLEY, GREGORY K (DC)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:K
Last Name:TILLEY
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 1:110 AMAYA DR
Mailing Address - Street 2:
Mailing Address - City:LYNCHBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24503-2264
Mailing Address - Country:US
Mailing Address - Phone:540-605-0253
Mailing Address - Fax:434-316-0103
Practice Address - Street 1:18853 FOREST RD
Practice Address - Street 2:
Practice Address - City:LYNCHBURG
Practice Address - State:VA
Practice Address - Zip Code:24502-4485
Practice Address - Country:US
Practice Address - Phone:434-316-0100
Practice Address - Fax:434-316-0103
Is Sole Proprietor?:No
Enumeration Date:2007-02-15
Last Update Date:2021-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA010400184111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAU67894Medicare UPIN
VA00V515T77Medicare ID - Type UnspecifiedINDIVIDUAL
VAC08777Medicare ID - Type UnspecifiedGROUP