Healthcare Provider Details

I. General information

NPI: 1609299312
Provider Name (Legal Business Name): MR. AUSTIN D LILLY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/31/2014
Last Update Date: 01/31/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

118 PEBBLESTONE DR
BECKLEY WV
25801-9524
US

IV. Provider business mailing address

118 PEBBLESTONE DR
BECKLEY WV
25801-9524
US

V. Phone/Fax

Practice location:
  • Phone: 304-237-4836
  • Fax:
Mailing address:
  • Phone: 304-237-4836
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code347C00000X
TaxonomyPrivate Vehicle
License NumberF072423
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: