1669588190 NPI number — LAKE NORMAN SLEEP CENTER, PA

Table of content: JENNIFER DENISE LILLY LPC (NPI 1437480696)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1669588190 NPI number — LAKE NORMAN SLEEP CENTER, PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LAKE NORMAN SLEEP CENTER, PA
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1669588190
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/21/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
170 MEDICAL PARK RD
Provider Second Line Business Mailing Address:
SUITE 103
Provider Business Mailing Address City Name:
MOORESVILLE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28117-8540
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
704-660-4094
Provider Business Mailing Address Fax Number:
704-660-8901

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
170 MEDICAL PARK RD
Provider Second Line Business Practice Location Address:
SUITE 103
Provider Business Practice Location Address City Name:
MOORESVILLE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28117-8540
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
704-660-4094
Provider Business Practice Location Address Fax Number:
704-660-8901
Provider Enumeration Date:
08/21/2006

Additional Information

Authorized Official

Authorized Official Last Name:
SURDULESCU
Authorized Official First Name:
SEVER
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
704-660-4094

Provider Taxonomy Codes

  • Taxonomy code: 207RP1001X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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