MEDICARE: WILLIS CHIRO MED OF MB

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111N00000X	Chiropractor	2486	SC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1649331000
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WILLIS CHIRO MED OF MB

Provider Business Mailing Address
First Line	:	1665 GLENNS BAY RD
Second Line	:
City	:	SURFSIDE BEACH
State	:	SC
Zip	:	29575-4836
Country	:	US
Telephone Number	:	843-215-2324
Fax Number	:	843-215-0541

Provider Business Practice Location Address
First Line	:	1665 GLENNS BAY RD
Second Line	:
City	:	SURFSIDE BEACH
State	:	SC
Zip	:	29575-4836
Country	:	US
Telephone Number	:	843-215-2324
Fax Number	:	843-215-0541

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. CHARLES T ROGERS JR.
Credential	:	D.C.
Telephone Number	:	843-215-2324

Provider Enumeration Date	:	12/12/2006
Last Update Date	:	05/30/2008

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Directions to “WILLIS CHIRO MED OF MB ” Practice Location

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