Provider Demographics
NPI:1053650531
Name:LILLIE, THEODORE ROBERT (DC)
Entity Type:Individual
Prefix:DR
First Name:THEODORE
Middle Name:ROBERT
Last Name:LILLIE
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2106 NE 47TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97213-2064
Mailing Address - Country:US
Mailing Address - Phone:503-282-7581
Mailing Address - Fax:503-269-5622
Practice Address - Street 1:2106 NE 47TH AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97213-2064
Practice Address - Country:US
Practice Address - Phone:503-282-7581
Practice Address - Fax:503-269-5622
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-04
Last Update Date:2022-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN5605111N00000X
OR5123111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor