Basic Information
| Provider Information | |||||||||
| NPI: | 1386207645 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LULL | ||||||||
| FirstName: | JEFFREY | ||||||||
| MiddleName: | FREEMAN | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 850 PETER BRYCE BLVD | ||||||||
| Address2: | |||||||||
| City: | TUSCALOOSA | ||||||||
| State: | AL | ||||||||
| PostalCode: | 354017457 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2053481770 | ||||||||
| FaxNumber: | 2053481772 | ||||||||
| Practice Location | |||||||||
| Address1: | 310 SUNNYVIEW LN | ||||||||
| Address2: | |||||||||
| City: | KALISPELL | ||||||||
| State: | MT | ||||||||
| PostalCode: | 599013129 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4067515310 | ||||||||
| FaxNumber: | 4067513068 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/22/2019 | ||||||||
| LastUpdateDate: | 09/01/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/01/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207Q00000X | MED-PHYS-LIC-114081 | MT | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.