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General NPI Number Information
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NPI Number | 1174784847
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Entity Type | Organization
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Legal Business Name | WILLIS CHIRO MED OF MB
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Dates
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Enumeration Date | 06/24/2008
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Last Update Date | 06/24/2008
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Provider Practice Location Address
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Address Line | 1665 GLENNS BAY RD
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City | SURFSIDE BEACH
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State | SC
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Zip | 29575-4836
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Country | US
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Telephone | 843-215-2324
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Fax | 843-215-0541
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Provider Business Mailing Address
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Address Line | 1665 GLENNS BAY RD
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City | SURFSIDE BEACH
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State | SC
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Zip | 29575-4836
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Country | US
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Telephone | 843-215-2324
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Fax | 843-215-0541
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Authorized Official
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Title or Position | OWNER
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Name | SCOTT WILLIS
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Credential | DC
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Telephone | 843-215-2324
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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 | 2486
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License Number State | SC
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