1134305857 NPI number — BONITA LILLIE RD

Table of content: BONITA LILLIE RD (NPI 1134305857)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134305857 NPI number — BONITA LILLIE RD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LILLIE
Provider First Name:
BONITA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
RD
Provider Gender Code:
F

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:
1134305857
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/18/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5412 CASTLE BAR LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ALEXANDRIA
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
22315-5519
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
703-879-5160
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2121 EISENHOWER AVE
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
ALEXANDRIA
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
22314-4698
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
703-519-0901
Provider Business Practice Location Address Fax Number:
703-519-0902
Provider Enumeration Date:
01/11/2008

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 133V00000X , with the licence number:  2004009119 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: G02785D01 . This is a "MEDICARE PTAN" identifier . This identifiers is of the category "OTHER".




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