Provider Demographics
NPI:1124449566
Name:LOLLI, RAYMOND
Entity type:Individual
Prefix:
First Name:RAYMOND
Middle Name:
Last Name:LOLLI
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:PO BOX 1557
Mailing Address - Street 2:
Mailing Address - City:FORT ASHBY
Mailing Address - State:WV
Mailing Address - Zip Code:26719-1557
Mailing Address - Country:US
Mailing Address - Phone:304-790-2468
Mailing Address - Fax:
Practice Address - Street 1:273 OAKPOINTE DRIVE
Practice Address - Street 2:
Practice Address - City:FORT ASHBY
Practice Address - State:WV
Practice Address - Zip Code:26719-1557
Practice Address - Country:US
Practice Address - Phone:304-790-2468
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-01-03
Last Update Date:2016-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV300225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist