Healthcare Provider Details

I. General information

NPI: 1174493357
Provider Name (Legal Business Name): LYERLY BAPTIST INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/11/2025
Last Update Date: 11/13/2025
Certification Date: 11/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3690 SAINT JOHNS BLUFF RD S
JACKSONVILLE FL
32224-2616
US

IV. Provider business mailing address

PO BOX 746647
ATLANTA GA
30374-6647
US

V. Phone/Fax

Practice location:
  • Phone: 904-202-6683
  • Fax: 904-376-3062
Mailing address:
  • Phone: 904-202-2092
  • Fax: 904-376-4075

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RS0010X
TaxonomySports Medicine (Internal Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: TYRONE MCCLOUD
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 904-202-5367