Provider Demographics
NPI:1982901567
Name:WILLIS, SCOTT (DC)
Entity type:Individual
Prefix:
First Name:SCOTT
Middle Name:
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 1:2105 CROMLEY CIR STE B
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29577-3168
Mailing Address - Country:US
Mailing Address - Phone:843-626-6666
Mailing Address - Fax:888-456-9396
Practice Address - Street 1:2105 CROMLEY CIR STE B
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29577-3168
Practice Address - Country:US
Practice Address - Phone:843-626-6666
Practice Address - Fax:888-456-9396
Is Sole Proprietor?:No
Enumeration Date:2011-02-17
Last Update Date:2011-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC997111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC1235436619OtherGROUP PRACTICE NPI
SC285258Medicaid
SC5316OtherMEDICARE PTAN