=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275986614
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOSEPH DAVID LYONS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/21/2016
-----------------------------------------------------
Last Update Date | 07/21/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1971 UNIVERSITY BLVD
-----------------------------------------------------
City | LYNCHBURG
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 24515-0002
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 434-582-7458
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1104 E LAWN DR APT 302
-----------------------------------------------------
City | FOREST
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 24551-2990
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 313-995-3146
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2255A2300X
-----------------------------------------------------
Taxonomy Name | Athletic Trainer
-----------------------------------------------------
License Number | 0126002321
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------