Healthcare Provider Details

I. General information

NPI: 1740515006
Provider Name (Legal Business Name): LYERLY BAPTIST INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/05/2009
Last Update Date: 07/25/2025
Certification Date: 07/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

836 PRUDENTIAL DR STE 1400
JACKSONVILLE FL
32207-8340
US

IV. Provider business mailing address

PO BOX 746647
ATLANTA GA
30374-6647
US

V. Phone/Fax

Practice location:
  • Phone: 904-388-6518
  • Fax: 904-384-1005
Mailing address:
  • Phone: 904-202-2092
  • Fax: 904-376-4075

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License Number
License Number State

VIII. Authorized Official

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