Healthcare Provider Details

I. General information

NPI: 1740602929
Provider Name (Legal Business Name): HAROLD RYAN LILLY LAC, EAMP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/07/2014
Last Update Date: 01/07/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10127 MAIN PL SUITE B
BOTHELL WA
98011-3402
US

IV. Provider business mailing address

14500 JUANITA DR NE G HALL 301
KENMORE WA
98028-4966
US

V. Phone/Fax

Practice location:
  • Phone: 425-780-6020
  • Fax:
Mailing address:
  • Phone: 425-780-6020
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberAC60392092
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberOM000165
License Number StatePA
# 3
Primary TaxonomyN
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberMED-ACU-LIC-26569
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: