=====================================================
General NPI Number Information
=====================================================
NPI Number | 1053495820
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LILLY EYE CARE, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/25/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2823 3RD AVE
-----------------------------------------------------
City | HUNTINGTON
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 25702-1423
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-523-3937
-----------------------------------------------------
Fax | 304-523-3945
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2823 3RD AVE
-----------------------------------------------------
City | HUNTINGTON
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 25702-1423
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-523-3937
-----------------------------------------------------
Fax | 304-523-3945
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. DALE BLAKE LILLY
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 304-523-3937
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM2500X
-----------------------------------------------------
Taxonomy Name | Medical Specialty Clinic/Center
-----------------------------------------------------
License Number | WV17041
-----------------------------------------------------
License Number State | WV
-----------------------------------------------------