Provider Demographics
NPI:1003130964
Name:LILY WELLNESS
Entity Type:Organization
Organization Name:LILY WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JAN
Authorized Official - Middle Name:
Authorized Official - Last Name:BEESON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:952-435-2661
Mailing Address - Street 1:1601 SOUTHCROSS DR W
Mailing Address - Street 2:
Mailing Address - City:BURNSVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55306-7013
Mailing Address - Country:US
Mailing Address - Phone:952-435-2661
Mailing Address - Fax:
Practice Address - Street 1:1601 SOUTHCROSS DR W
Practice Address - Street 2:
Practice Address - City:BURNSVILLE
Practice Address - State:MN
Practice Address - Zip Code:55306-7013
Practice Address - Country:US
Practice Address - Phone:952-435-2661
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-22
Last Update Date:2010-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNCFM02120335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier