Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NR0400X | Rehabilitation Chiropractor | 038.012119 | IL |
NPI | 1154694859 |
---|---|
Provider Name | Dr. Bryne Paul Willey |
First Address | Bloomington, IL 61704-9399 |
Second Address | Bloomington, IL 61704-9399 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 12/02/2012 |
Last Update Date | 25/06/2012 |