Individual ProviderNicole WillisChiropractorChiropractic ProvidersPractice Address1570 E Heritage Park St, Ste 175, Meridian, ID 83646-6445(208) 322-4114PECOS EnrollmentBased on the most recent information from CMS, provider Nicole Willis does not have current enrollment records in PECOS.Part BMedicare Part BNot EnrolledHHAHome Health AgencyNot EnrolledDMEDurable Medical EquipmentNot EnrolledPMDPower Mobility DeviceNot EnrolledCMS last updated its PECOS records 2 days ago.Profile DetailsProvider ID1093992539Provider TypeIndividualFull NameWillis, NicoleCredentialD.C.GenderFemaleSole ProprietorNoEnumeration Date1/28/2008Last Updated1/31/2020Contact InformationPractice LocationPractice Address1570 E Heritage Park St, Ste 175, Meridian, ID 83646-6445Phone(208) 322-4114Fax(208) 322-4115Mailing LocationMailing Address1570 E Heritage Park St, Ste 175, Meridian, ID 83646-6445Phone(208) 322-4114Fax(208) 322-4115Provider TaxonomiesCodeDescriptionLicenseCode111N00000XPrimaryDescriptionChiropractorChiropractic ProvidersLicenseCHIA-1268IdahoProvider IdentifiersIDDescriptionIssuerID1370103DescriptionOtherIssuerGROUP PTAN