Provider Demographics
NPI:1699312173
Name:WILLIS, JUSTIN WAYNE (DC)
Entity type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:WAYNE
Last Name:WILLIS
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:210 SEMINOLE AVE
Mailing Address - Street 2:
Mailing Address - City:ORMOND BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32176-8129
Mailing Address - Country:US
Mailing Address - Phone:305-491-4171
Mailing Address - Fax:
Practice Address - Street 1:225 N CAUSEWAY
Practice Address - Street 2:
Practice Address - City:NEW SMYRNA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32169-5239
Practice Address - Country:US
Practice Address - Phone:386-424-9977
Practice Address - Fax:386-423-3899
Is Sole Proprietor?:No
Enumeration Date:2019-12-04
Last Update Date:2019-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL12993111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor