MEDICARE: WILLIS FAMILY CHIROPRACTIC, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111N00000X	Chiropractor	CHIA-1268, CHIA-1267	ID

General Provider Information

NPI Number	:	1114191137
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WILLIS FAMILY CHIROPRACTIC, LLC

Provider Business Mailing Address
First Line	:	10451 W GARVERDALE CT
Second Line	:	SUITE 201
City	:	BOISE
State	:	ID
Zip	:	83704-5408
Country	:	US
Telephone Number	:	208-322-4114
Fax Number	:	208-322-4115

Provider Business Practice Location Address
First Line	:	10451 W GARVERDALE CT
Second Line	:	SUITE 201
City	:	BOISE
State	:	ID
Zip	:	83704-5408
Country	:	US
Telephone Number	:	208-322-4114
Fax Number	:	208-322-4115

Authorized Official
Title or Position	:	CHIROPRACTOR, OWNER
Name	:	DR. NICOLE WILLIS
Credential	:	DC
Telephone Number	:	208-322-4114

Provider Enumeration Date	:	04/22/2008
Last Update Date	:	10/06/2008

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