Provider Demographics
NPI:1609299312
Name:LILLY, AUSTIN D
Entity Type:Individual
Prefix:MR
First Name:AUSTIN
Middle Name:D
Last Name:LILLY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:118 PEBBLESTONE DR
Mailing Address - Street 2:
Mailing Address - City:BECKLEY
Mailing Address - State:WV
Mailing Address - Zip Code:25801-9524
Mailing Address - Country:US
Mailing Address - Phone:304-237-4836
Mailing Address - Fax:
Practice Address - Street 1:118 PEBBLESTONE DR
Practice Address - Street 2:
Practice Address - City:BECKLEY
Practice Address - State:WV
Practice Address - Zip Code:25801-9524
Practice Address - Country:US
Practice Address - Phone:304-237-4836
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-31
Last Update Date:2014-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVF072423347C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes347C00000XTransportation ServicesPrivate Vehicle