Provider Demographics
NPI:1720025141
Name:LILYQUIST, KENTON L (OD)
Entity Type:Individual
Prefix:DR
First Name:KENTON
Middle Name:L
Last Name:LILYQUIST
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1813 W EHRINGHAUS ST
Mailing Address - Street 2:
Mailing Address - City:ELIZABETH CITY
Mailing Address - State:NC
Mailing Address - Zip Code:27909-4555
Mailing Address - Country:US
Mailing Address - Phone:252-333-1155
Mailing Address - Fax:252-451-5330
Practice Address - Street 1:1813 W EHRINGHAUS ST
Practice Address - Street 2:
Practice Address - City:ELIZABETH CITY
Practice Address - State:NC
Practice Address - Zip Code:27909-4555
Practice Address - Country:US
Practice Address - Phone:252-333-1155
Practice Address - Fax:252-451-5330
Is Sole Proprietor?:No
Enumeration Date:2006-06-02
Last Update Date:2010-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0897152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC09533OtherBCBSNC INDIVIDUAL NUMBER
NC8909533Medicaid
NC246222BMedicare PIN