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General NPI Number Information
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NPI Number | 1295374270
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Entity Type | Organization
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Legal Business Name | LILLY AESTHETICS SC
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Dates
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Enumeration Date | 12/23/2019
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Last Update Date | 12/23/2019
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Provider Practice Location Address
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Address Line | 2500 S HIGHLAND AVE STE 220
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City | LOMBARD
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State | IL
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Zip | 60148-7103
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Country | US
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Telephone | 630-317-7338
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 644
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City | MARQUETTE
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State | MI
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Zip | 49855-0644
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | MERCY ODUEYUNGBO
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Credential | MD
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Telephone | 630-317-7338
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207ND0101X
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Taxonomy Name | MOHS-Micrographic Surgery Physician
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License Number |
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License Number State |
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