Healthcare Provider Details

I. General information

NPI: 1043757107
Provider Name (Legal Business Name): WILLS INTEGRATED HEALTH LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/27/2017
Last Update Date: 01/27/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

102 MAPLE AVE
ROCHELLE IL
61068-8926
US

IV. Provider business mailing address

102 MAPLE AVE
ROCHELLE IL
61068-8926
US

V. Phone/Fax

Practice location:
  • Phone: 815-562-5333
  • Fax: 815-562-5833
Mailing address:
  • Phone: 815-562-5333
  • Fax: 815-562-5833

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: BRIAN WILLS
Title or Position: OWNER
Credential:
Phone: 815-562-5333