Healthcare Provider Details

I. General information

NPI: 1962736413
Provider Name (Legal Business Name): LYERLY BAPTIST INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/30/2009
Last Update Date: 09/30/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2736 UNIVERSITY BLVD W SUITE 3
JACKSONVILLE FL
32217-2179
US

IV. Provider business mailing address

2736 UNIVERSITY BLVD W SUITE 3
JACKSONVILLE FL
32217-2179
US

V. Phone/Fax

Practice location:
  • Phone: 904-733-4262
  • Fax: 904-636-5786
Mailing address:
  • Phone: 904-733-4262
  • Fax: 904-636-5786

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number
License Number State

VIII. Authorized Official

Name: JOHN WILBANKS
Title or Position: CHIEF OPERATING OFFICER
Credential:
Phone: 904-376-4275