Provider Demographics
NPI:1477225308
Name:LILLIS, BRIAN R
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:R
Last Name:LILLIS
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 1:470 E BULLOCH ST
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:UT
Mailing Address - Zip Code:84780-1774
Mailing Address - Country:US
Mailing Address - Phone:208-473-6880
Mailing Address - Fax:
Practice Address - Street 1:470 E BULLOCH ST
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:UT
Practice Address - Zip Code:84780-1774
Practice Address - Country:US
Practice Address - Phone:208-473-6880
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-29
Last Update Date:2021-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT12435793374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes374U00000XNursing Service Related ProvidersHome Health AideGroup - Single Specialty