Provider Demographics
NPI:1790061141
Name:LILLY, CARMEN I (LAC)
Entity Type:Individual
Prefix:MS
First Name:CARMEN
Middle Name:I
Last Name:LILLY
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:405 W CENTRAL PKWY
Mailing Address - Street 2:SUITE 1010
Mailing Address - City:ALTAMONTE SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32714-2441
Mailing Address - Country:US
Mailing Address - Phone:407-774-8877
Mailing Address - Fax:
Practice Address - Street 1:405 W CENTRAL PKWY
Practice Address - Street 2:SUITE 1010
Practice Address - City:ALTAMONTE SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:32714-2441
Practice Address - Country:US
Practice Address - Phone:407-774-8877
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-31
Last Update Date:2011-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL969171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist