Provider Demographics
NPI:1063659035
Name:ROXANNE ELOUISE LILLIS
Entity Type:Organization
Organization Name:ROXANNE ELOUISE LILLIS
Other - Org Name:AT HOME AGENCY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:ROXANNE
Authorized Official - Middle Name:ELOUISE
Authorized Official - Last Name:LILLIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:218-226-4496
Mailing Address - Street 1:4215 BEAVER VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:SILVER BAY
Mailing Address - State:MN
Mailing Address - Zip Code:55614-3808
Mailing Address - Country:US
Mailing Address - Phone:218-226-4496
Mailing Address - Fax:
Practice Address - Street 1:4215 BEAVER VALLEY RD
Practice Address - Street 2:
Practice Address - City:SILVER BAY
Practice Address - State:MN
Practice Address - Zip Code:55614-3808
Practice Address - Country:US
Practice Address - Phone:218-226-4496
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-13
Last Update Date:2009-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN342529251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health