Provider Demographics
NPI:1649331000
Name:WILLIS CHIRO MED OF MB
Entity type:Organization
Organization Name:WILLIS CHIRO MED OF MB
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:T
Authorized Official - Last Name:ROGERS
Authorized Official - Suffix:JR
Authorized Official - Credentials:DC
Authorized Official - Phone:843-215-2324
Mailing Address - Street 1:1665 GLENNS BAY RD
Mailing Address - Street 2:
Mailing Address - City:SURFSIDE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29575-4836
Mailing Address - Country:US
Mailing Address - Phone:843-215-2324
Mailing Address - Fax:843-215-0541
Practice Address - Street 1:1665 GLENNS BAY RD
Practice Address - Street 2:
Practice Address - City:SURFSIDE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29575-4836
Practice Address - Country:US
Practice Address - Phone:843-215-2324
Practice Address - Fax:843-215-0541
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-12
Last Update Date:2008-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2486111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCCH2486Medicaid
SCCH2486Medicaid