Provider Demographics
NPI:1427471515
Name:DR. HAILEY E WILLIS, PLLC
Entity type:Organization
Organization Name:DR. HAILEY E WILLIS, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:HAILEY
Authorized Official - Middle Name:
Authorized Official - Last Name:WILLIS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:903-455-0294
Mailing Address - Street 1:5200 WESLEY ST
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75402-6309
Mailing Address - Country:US
Mailing Address - Phone:903-455-0294
Mailing Address - Fax:903-455-2747
Practice Address - Street 1:5200 WESLEY ST
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:TX
Practice Address - Zip Code:75402-6309
Practice Address - Country:US
Practice Address - Phone:903-455-0294
Practice Address - Fax:903-455-2747
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-27
Last Update Date:2014-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX7875TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
269778YXEQMedicare PIN