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General NPI Number Information
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NPI Number | 1922419605
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Entity Type | Individual
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Provider Name | DR. BRADLEY WILLIS
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Gender | Male
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Dates
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Enumeration Date | 05/15/2014
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Last Update Date | 05/15/2014
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Provider Practice Location Address
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Address Line | 105 N MAIN ST
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City | ATHENS
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State | IL
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Zip | 62613-8901
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Country | US
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Telephone | 217-636-7388
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 65
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City | ATHENS
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State | IL
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Zip | 62613-0065
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174M00000X
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Taxonomy Name | Veterinarian
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License Number | 090008708
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License Number State | IL
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