Healthcare Provider Details

I. General information

NPI: 1467776385
Provider Name (Legal Business Name): LIL FAMILY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/22/2010
Last Update Date: 03/31/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2401 W UNIVERSITY AVE
MUNCIE IN
47303-3428
US

IV. Provider business mailing address

2401 W UNIVERSITY AVE
MUNCIE IN
47303-3428
US

V. Phone/Fax

Practice location:
  • Phone: 800-606-0430
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0001X
TaxonomyClinical Cardiac Electrophysiology Physician
License Number
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code2085N0904X
TaxonomyNuclear Radiology Physician
License Number
License Number StateIN

VIII. Authorized Official

Name: GARY R BRIGHAM
Title or Position: PRESIDENT
Credential: MD
Phone: 800-606-0430