Provider Demographics
NPI:1104952043
Name:LILLY, LOREN EDGAR (RRT)
Entity type:Individual
Prefix:MR
First Name:LOREN
Middle Name:EDGAR
Last Name:LILLY
Suffix:
Gender:M
Credentials:RRT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4119 EAST JUANITA AVE.
Mailing Address - Street 2:
Mailing Address - City:HIGLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:85236
Mailing Address - Country:US
Mailing Address - Phone:480-292-1328
Mailing Address - Fax:
Practice Address - Street 1:6343 EAST MAIN STREET
Practice Address - Street 2:SUITE 8
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85205
Practice Address - Country:US
Practice Address - Phone:480-325-8838
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ17592279P1005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2279P1005XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRespiratory Therapist, RegisteredPulmonary Rehabilitation