Healthcare Provider Details

I. General information

NPI: 1750401964
Provider Name (Legal Business Name): WILLIS MEDICAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/30/2007
Last Update Date: 05/09/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 FACTORY OUTLET DR SUITE 12
ARCADIA LA
71001-3057
US

IV. Provider business mailing address

600 FACTORY OUTLET DR SUITE 12
ARCADIA LA
71001-3057
US

V. Phone/Fax

Practice location:
  • Phone: 318-263-4701
  • Fax: 318-263-4704
Mailing address:
  • Phone: 318-263-4701
  • Fax: 318-263-4704

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD.018544
License Number StateLA

VIII. Authorized Official

Name: MISS MELINDA WILLIS
Title or Position: OWNER
Credential: MD
Phone: 318-263-4701