=====================================================
General NPI Number Information
=====================================================
NPI Number | 1619028008
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LILLY WILEN M.D. A MEDICAL CORPORATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/15/2007
-----------------------------------------------------
Last Update Date | 01/05/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 17075 DEVONSHIRE ST SUITE 306
-----------------------------------------------------
City | NORTHRIDGE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91325-1600
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-831-3228
-----------------------------------------------------
Fax | 818-831-3447
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 17075 DEVONSHIRE ST SUITE 306
-----------------------------------------------------
City | NORTHRIDGE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91325-1600
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-831-3227
-----------------------------------------------------
Fax | 818-831-3447
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | LILLY WILEN
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 818-831-3227
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM2500X
-----------------------------------------------------
Taxonomy Name | Medical Specialty Clinic/Center
-----------------------------------------------------
License Number | A61876
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------