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General NPI Number Information
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NPI Number | 1598730434
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Entity Type | Individual
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Provider Name | TOM LYLE ATC
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Gender | Male
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Dates
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Enumeration Date | 02/22/2006
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 400 W ELM AVE FLAGSTAFF HIGH SCHOOL
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City | FLAGSTAFF
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State | AZ
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Zip | 86001-1562
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Country | US
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Telephone | 928-527-1531
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Fax | 928-773-8146
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Provider Business Mailing Address
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Address Line | 3464 NE RAINIER LOOP
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City | FLAGSTAFF
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State | AZ
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Zip | 86004-1747
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Country | US
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Telephone | 928-527-1531
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | 0036
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License Number State | AZ
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