Provider Demographics
NPI:1063619567
Name:WILLIS CLINIC
Entity type:Organization
Organization Name:WILLIS CLINIC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:COO/PRACTICE MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:W
Authorized Official - Last Name:WILLIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:870-563-2545
Mailing Address - Street 1:616 W LEE AVE
Mailing Address - Street 2:
Mailing Address - City:OSCEOLA
Mailing Address - State:AR
Mailing Address - Zip Code:72370-3002
Mailing Address - Country:US
Mailing Address - Phone:870-563-2545
Mailing Address - Fax:870-563-2482
Practice Address - Street 1:616 W LEE AVE
Practice Address - Street 2:
Practice Address - City:OSCEOLA
Practice Address - State:AR
Practice Address - Zip Code:72370-3002
Practice Address - Country:US
Practice Address - Phone:870-563-2545
Practice Address - Fax:870-563-2482
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-28
Last Update Date:2021-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE5031261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR165422001Medicaid