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General NPI Number Information
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NPI Number | 1114191137
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Entity Type | Organization
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Legal Business Name | WILLIS FAMILY CHIROPRACTIC, LLC
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Dates
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Enumeration Date | 04/22/2008
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Last Update Date | 10/06/2008
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Provider Practice Location Address
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Address Line | 10451 W GARVERDALE CT SUITE 201
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City | BOISE
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State | ID
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Zip | 83704-5408
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Country | US
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Telephone | 208-322-4114
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Fax | 208-322-4115
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Provider Business Mailing Address
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Address Line | 10451 W GARVERDALE CT SUITE 201
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City | BOISE
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State | ID
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Zip | 83704-5408
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Country | US
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Telephone | 208-322-4114
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Fax | 208-322-4115
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Authorized Official
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Title or Position | CHIROPRACTOR, OWNER
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Name | DR. NICOLE WILLIS
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Credential | DC
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Telephone | 208-322-4114
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 111N00000X
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Taxonomy Name | Chiropractor
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License Number | CHIA-1268, CHIA-1267
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License Number State | ID
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