Healthcare Provider Details

I. General information

NPI: 1134499452
Provider Name (Legal Business Name): LLY VISION SERVICES INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/03/2012
Last Update Date: 01/19/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 MARY ESTHER BLVD STE. #47
MARY ESTHER FL
32569-1693
US

IV. Provider business mailing address

PO BOX 5836
DESTIN FL
32540-5836
US

V. Phone/Fax

Practice location:
  • Phone: 850-664-6339
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPC2570
License Number StateFL

VIII. Authorized Official

Name: DR. LOUIS YARDLEY JR.
Title or Position: PRESIDENT
Credential: O.D.
Phone: 850-240-2021