Provider Demographics
NPI:1992466189
Name:WILLS, BLAKE TYLER
Entity type:Individual
Prefix:
First Name:BLAKE
Middle Name:TYLER
Last Name:WILLS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:416 VALLEY VIEW DR STE 1300
Mailing Address - Street 2:
Mailing Address - City:SCOTTSBLUFF
Mailing Address - State:NE
Mailing Address - Zip Code:69361-1459
Mailing Address - Country:US
Mailing Address - Phone:308-436-7176
Mailing Address - Fax:
Practice Address - Street 1:416 VALLEY VIEW DR STE 1300
Practice Address - Street 2:
Practice Address - City:SCOTTSBLUFF
Practice Address - State:NE
Practice Address - Zip Code:69361-1459
Practice Address - Country:US
Practice Address - Phone:308-436-7176
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-10
Last Update Date:2022-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE2122111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor