Provider Demographics
NPI:1467070961
Name:LILLY, ALIX RAE (DC)
Entity Type:Individual
Prefix:
First Name:ALIX
Middle Name:RAE
Last Name:LILLY
Suffix:
Gender:F
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:PO BOX 63
Mailing Address - Street 2:
Mailing Address - City:DAVIS
Mailing Address - State:WV
Mailing Address - Zip Code:26260-0063
Mailing Address - Country:US
Mailing Address - Phone:304-668-1198
Mailing Address - Fax:
Practice Address - Street 1:245 THOMAS AVE
Practice Address - Street 2:
Practice Address - City:DAVIS
Practice Address - State:WV
Practice Address - Zip Code:26260
Practice Address - Country:US
Practice Address - Phone:304-668-1198
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-10
Last Update Date:2020-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV1027111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty