=====================================================
General NPI Number Information
=====================================================
NPI Number | 1174389688
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | WILLIE J LYONS JR. LMT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/22/2024
-----------------------------------------------------
Last Update Date | 02/22/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 300 BERKSHIRE DR STE C
-----------------------------------------------------
City | COLUMBIA
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29223-1859
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 803-906-0301
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 120 BENT OAK TRL
-----------------------------------------------------
City | BLYTHEWOOD
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29016-8380
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 719-205-6605
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number | 11403
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------