Provider Demographics
NPI:1780632422
Name:WILLIS, RANDY JOE (DC)
Entity type:Individual
Prefix:
First Name:RANDY
Middle Name:JOE
Last Name:WILLIS
Suffix:
Gender:
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:242 OAK AVE STE 155
Mailing Address - Street 2:
Mailing Address - City:KANNAPOLIS
Mailing Address - State:NC
Mailing Address - Zip Code:28081-4329
Mailing Address - Country:US
Mailing Address - Phone:980-330-1680
Mailing Address - Fax:
Practice Address - Street 1:607 RAINBOW DR
Practice Address - Street 2:
Practice Address - City:KANNAPOLIS
Practice Address - State:NC
Practice Address - Zip Code:28081-4746
Practice Address - Country:US
Practice Address - Phone:704-652-1393
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-05
Last Update Date:2025-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC3043111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor