Healthcare Provider Details

I. General information

NPI: 1356442651
Provider Name (Legal Business Name): JEFFREY B WILLES DC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/26/2006
Last Update Date: 12/13/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

664 14TH STREET EAST
ELY NV
89301
US

IV. Provider business mailing address

664 14TH STREET EAST
ELY NV
89301
US

V. Phone/Fax

Practice location:
  • Phone: 775-289-6800
  • Fax: 775-289-2579
Mailing address:
  • Phone: 775-289-6800
  • Fax: 775-289-2579

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number565B
License Number StateNV
# 2
Primary TaxonomyN
Taxonomy Code111NS0005X
TaxonomySports Physician Chiropractor
License Number4182
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: