Healthcare Provider Details

I. General information

NPI: 1811748403
Provider Name (Legal Business Name): TIMOTHY LYTLE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/01/2024
Last Update Date: 04/01/2024
Certification Date: 03/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 SALEM AVE
DAYTON OH
45406-5144
US

IV. Provider business mailing address

1100 SALEM AVE
DAYTON OH
45406-5144
US

V. Phone/Fax

Practice location:
  • Phone: 937-586-8462
  • Fax:
Mailing address:
  • Phone: 937-586-8462
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code347C00000X
TaxonomyPrivate Vehicle
License NumberTJ114743
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: