Healthcare Provider Details

I. General information

NPI: 1134636491
Provider Name (Legal Business Name): LYNLEY E ATWOOD, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/08/2018
Last Update Date: 01/08/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

422 W BETHALTO DR
BETHALTO IL
62010
US

IV. Provider business mailing address

422 W BETHALTO DR
BETHALTO IL
62010-1910
US

V. Phone/Fax

Practice location:
  • Phone: 618-377-5221
  • Fax:
Mailing address:
  • Phone: 618-377-5221
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number046.007313
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number046.011008
License Number StateIL

VIII. Authorized Official

Name: DR. LYNLEY E ATWOOD
Title or Position: MANAGER
Credential: OD
Phone: 618-377-5221