Healthcare Provider Details

I. General information

NPI: 1053495820
Provider Name (Legal Business Name): LILLY EYE CARE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/25/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2823 3RD AVE
HUNTINGTON WV
25702-1423
US

IV. Provider business mailing address

2823 3RD AVE
HUNTINGTON WV
25702-1423
US

V. Phone/Fax

Practice location:
  • Phone: 304-523-3937
  • Fax: 304-523-3945
Mailing address:
  • Phone: 304-523-3937
  • Fax: 304-523-3945

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License NumberWV17041
License Number StateWV

VIII. Authorized Official

Name: DR. DALE BLAKE LILLY
Title or Position: PRESIDENT
Credential: MD
Phone: 304-523-3937