MEDICARE: DR. KENTON L LILYQUIST OD

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	152W00000X	Optometrist	0897	NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	09533	OTHER	NC	BCBSNC INDIVIDUAL NUMBER
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1720025141
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KENTON L LILYQUIST OD

Provider Business Mailing Address
First Line	:	1813 W EHRINGHAUS ST
Second Line	:
City	:	ELIZABETH CITY
State	:	NC
Zip	:	27909-4555
Country	:	US
Telephone Number	:	252-333-1155
Fax Number	:	252-451-5330

Provider Business Practice Location Address
First Line	:	1813 W EHRINGHAUS ST
Second Line	:
City	:	ELIZABETH CITY
State	:	NC
Zip	:	27909-4555
Country	:	US
Telephone Number	:	252-333-1155
Fax Number	:	252-451-5330

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/02/2006
Last Update Date	:	06/03/2010

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