Provider Demographics
NPI:1487754644
Name:GILLENWATER, BILL HAYWOOD (DC)
Entity type:Individual
Prefix:DR
First Name:BILL
Middle Name:HAYWOOD
Last Name:GILLENWATER
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 1:1392 E CENTER ST
Mailing Address - Street 2:
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37664-2445
Mailing Address - Country:US
Mailing Address - Phone:423-378-4907
Mailing Address - Fax:423-578-8204
Practice Address - Street 1:1392 E CENTER ST
Practice Address - Street 2:
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37664-2445
Practice Address - Country:US
Practice Address - Phone:423-378-4907
Practice Address - Fax:423-578-8204
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN241DC111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3672076Medicare ID - Type Unspecified
TNT74490Medicare UPIN