Provider Demographics
NPI:1053598599
Name:WILLIS, CHAD C (DC)
Entity type:Individual
Prefix:
First Name:CHAD
Middle Name:C
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 1:12224 W BOWMONT ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83713-0021
Mailing Address - Country:US
Mailing Address - Phone:208-602-1573
Mailing Address - Fax:
Practice Address - Street 1:1565 E LEIGHFIELD DR STE 150
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83646-5371
Practice Address - Country:US
Practice Address - Phone:208-855-0585
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-28
Last Update Date:2008-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDCHIA-1267111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor