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General NPI Number Information
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NPI Number | 1063619567
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Entity Type | Organization
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Legal Business Name | WILLIS CLINIC
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Dates
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Enumeration Date | 06/28/2007
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Last Update Date | 01/20/2021
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Provider Practice Location Address
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Address Line | 616 W LEE AVE
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City | OSCEOLA
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State | AR
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Zip | 72370-3002
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Country | US
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Telephone | 870-563-2545
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Fax | 870-563-2482
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Provider Business Mailing Address
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Address Line | 616 W LEE AVE
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City | OSCEOLA
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State | AR
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Zip | 72370-3002
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Country | US
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Telephone | 870-563-2545
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Fax | 870-563-2482
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Authorized Official
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Title or Position | COO/PRACTICE MANAGER
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Name | MR. TIMOTHY W WILLIS
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Credential |
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Telephone | 870-563-2545
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP2300X
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Taxonomy Name | Primary Care Clinic/Center
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License Number | E5031
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License Number State | AR
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