Provider Demographics
NPI:1942382890
Name:WILLIS, MARSHALL M (DC)
Entity Type:Individual
Prefix:DR
First Name:MARSHALL
Middle Name:M
Last Name:WILLIS
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:PO BOX 340
Mailing Address - Street 2:
Mailing Address - City:OVERGAARD
Mailing Address - State:AZ
Mailing Address - Zip Code:85933-0340
Mailing Address - Country:US
Mailing Address - Phone:928-535-6421
Mailing Address - Fax:
Practice Address - Street 1:2947 HWY 260
Practice Address - Street 2:#3
Practice Address - City:OVERGAARD
Practice Address - State:AZ
Practice Address - Zip Code:85933
Practice Address - Country:US
Practice Address - Phone:928-535-6421
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ5288111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor