MEDICARE: LILY MEDICAL, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	332B00000X	Durable Medical Equipment & Medical Supplies	L14000135305	FL

General Provider Information

NPI Number	:	1669873469
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LILY MEDICAL, LLC

Provider Business Mailing Address
First Line	:	PO BOX 743122
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30374-3122
Country	:	US
Telephone Number	:	573-893-7111
Fax Number	:	573-415-0413

Provider Business Practice Location Address
First Line	:	7680 UNIVERSAL BLVD
Second Line	:	STE 575
City	:	ORLANDO
State	:	FL
Zip	:	32819-8900
Country	:	US
Telephone Number	:	573-893-7111
Fax Number	:	573-415-0413

Authorized Official
Title or Position	:	OWNER
Name	:	PATRICK TOMASSI
Credential	:
Telephone Number	:	537-893-7111

Provider Enumeration Date	:	09/11/2014
Last Update Date	:	10/27/2014

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