Provider Demographics
NPI:1699834697
Name:MEDIPRACTIC LLC
Entity type:Organization
Organization Name:MEDIPRACTIC LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SEC
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:E
Authorized Official - Last Name:WILLIS
Authorized Official - Suffix:
Authorized Official - Credentials:DC CDE1 DAAPM
Authorized Official - Phone:770-496-0326
Mailing Address - Street 1:3955 HARRISON RD
Mailing Address - Street 2:STE. 400
Mailing Address - City:LOGANVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30052-8501
Mailing Address - Country:US
Mailing Address - Phone:770-496-0326
Mailing Address - Fax:770-492-9599
Practice Address - Street 1:3955 HARRISON RD
Practice Address - Street 2:STE. 400
Practice Address - City:LOGANVILLE
Practice Address - State:GA
Practice Address - Zip Code:30052-8501
Practice Address - Country:US
Practice Address - Phone:770-496-0326
Practice Address - Fax:770-492-9599
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-06
Last Update Date:2012-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes204C00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine, Sports MedicineGroup - Multi-Specialty