Provider Demographics
NPI:1679683254
Name:GILLEAN, LEXINGTON KELVY II
Entity Type:Individual
Prefix:
First Name:LEXINGTON
Middle Name:KELVY
Last Name:GILLEAN
Suffix:II
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 1:3223 S LOOP 289
Mailing Address - Street 2:STE 101
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79423-8312
Mailing Address - Country:US
Mailing Address - Phone:806-744-7223
Mailing Address - Fax:806-740-3325
Practice Address - Street 1:2804 N LOOP 289
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79415-1410
Practice Address - Country:US
Practice Address - Phone:806-744-7223
Practice Address - Fax:806-740-3325
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2012-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX205001501Medicaid
TX1156657OtherLICENSE #
TX205001501Medicaid