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General NPI Number Information
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NPI Number | 1366403529
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Entity Type | Organization
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Legal Business Name | WILLIS CHIRO MED OF COLUMBIA, INC.
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Dates
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Enumeration Date | 03/29/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 7171 TWO NOTCH RD
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City | COLUMBIA
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State | SC
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Zip | 29223-7501
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Country | US
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Telephone | 803-699-0293
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Fax | 803-699-5087
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Provider Business Mailing Address
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Address Line | PO BOX 290096
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City | COLUMBIA
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State | SC
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Zip | 29229-0002
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Country | US
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Telephone | 803-699-0293
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Fax | 803-699-5087
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Authorized Official
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Title or Position | SENIOR OM
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Name | MS. SUELLYN GARD WILLIS
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Credential |
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Telephone | 803-699-0293
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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 | 1078
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License Number State | SC
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