Provider Demographics
NPI:1316169543
Name:LILLEMO, SCOTT LEE
Entity type:Individual
Prefix:
First Name:SCOTT
Middle Name:LEE
Last Name:LILLEMO
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 1:8827 N GOVERNMENT WAY
Mailing Address - Street 2:
Mailing Address - City:HAYDEN
Mailing Address - State:ID
Mailing Address - Zip Code:83835-8231
Mailing Address - Country:US
Mailing Address - Phone:208-762-3455
Mailing Address - Fax:
Practice Address - Street 1:8827 N GOVERNMENT WAY
Practice Address - Street 2:
Practice Address - City:HAYDEN
Practice Address - State:ID
Practice Address - Zip Code:83835-8231
Practice Address - Country:US
Practice Address - Phone:208-762-3455
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-03
Last Update Date:2008-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDV7778OtherBLUE CROSS OF IDAHO
ID000010138836OtherREGENCE BLUE SHIELD OF ID
IDV7778OtherBLUE CROSS OF IDAHO