Provider Demographics
NPI:1306950167
Name:WILLIS, RICHARD TROY (DC)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:TROY
Last Name:WILLIS
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3730 FRANKFORT AVE
Mailing Address - Street 2:#203
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40207-2582
Mailing Address - Country:US
Mailing Address - Phone:502-409-9300
Mailing Address - Fax:502-409-9307
Practice Address - Street 1:3730 FRANKFORT AVE
Practice Address - Street 2:#203
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-2582
Practice Address - Country:US
Practice Address - Phone:502-409-9300
Practice Address - Fax:502-409-9307
Is Sole Proprietor?:No
Enumeration Date:2006-08-18
Last Update Date:2011-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY4799111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYV01306Medicare UPIN
KY0902802Medicare PIN