Healthcare Provider Details

I. General information

NPI: 1477735694
Provider Name (Legal Business Name): JOHN P LYLES OPTOMETRIST
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/29/2007
Last Update Date: 03/15/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

43 INDUSTRIAL PARKWAY
CALVERT CITY KY
42029
US

IV. Provider business mailing address

PO BOX 7451
PADUCAH KY
42002-7451
US

V. Phone/Fax

Practice location:
  • Phone: 270-395-8331
  • Fax: 270-395-5360
Mailing address:
  • Phone: 270-443-9904
  • Fax: 270-575-0717

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1292DT
License Number StateKY

VIII. Authorized Official

Name: JOHN LYLES
Title or Position: OPTOMETRIST
Credential: O.D.
Phone: 270-395-8331