Provider Demographics
NPI:1700565421
Name:LILL, MINDY MARIE
Entity type:Individual
Prefix:
First Name:MINDY
Middle Name:MARIE
Last Name:LILL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:816 S BEACON BLVD APT 64
Mailing Address - Street 2:
Mailing Address - City:GRAND HAVEN
Mailing Address - State:MI
Mailing Address - Zip Code:49417-2291
Mailing Address - Country:US
Mailing Address - Phone:231-855-5826
Mailing Address - Fax:
Practice Address - Street 1:14700 US HIGHWAY 31
Practice Address - Street 2:
Practice Address - City:GRAND HAVEN
Practice Address - State:MI
Practice Address - Zip Code:49417-8390
Practice Address - Country:US
Practice Address - Phone:616-844-5011
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-12
Last Update Date:2023-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI240354156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician