Healthcare Provider Details

I. General information

NPI: 1699834697
Provider Name (Legal Business Name): MEDIPRACTIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/06/2006
Last Update Date: 12/21/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3955 HARRISON RD STE. 400
LOGANVILLE GA
30052-8501
US

IV. Provider business mailing address

3955 HARRISON RD STE. 400
LOGANVILLE GA
30052-8501
US

V. Phone/Fax

Practice location:
  • Phone: 770-496-0326
  • Fax: 770-492-9599
Mailing address:
  • Phone: 770-496-0326
  • Fax: 770-492-9599

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204C00000X
TaxonomySports Medicine (Neuromusculoskeletal Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. WILLIAM E WILLIS
Title or Position: SEC
Credential: DC CDE1 DAAPM
Phone: 770-496-0326