Healthcare Provider Details

I. General information

NPI: 1104952043
Provider Name (Legal Business Name): LOREN EDGAR LILLY RRT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/26/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6343 EAST MAIN STREET SUITE 8
MESA AZ
85205
US

IV. Provider business mailing address

4119 EAST JUANITA AVE.
HIGLEY AZ
85236
US

V. Phone/Fax

Practice location:
  • Phone: 480-325-8838
  • Fax:
Mailing address:
  • Phone: 480-292-1328
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2279P1005X
TaxonomyPulmonary Rehabilitation Registered Respiratory Therapist
License Number1759
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: