Provider Demographics
NPI:1134499452
Name:LLY VISION SERVICES INC.
Entity Type:Organization
Organization Name:LLY VISION SERVICES INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LOUIS
Authorized Official - Middle Name:
Authorized Official - Last Name:YARDLEY
Authorized Official - Suffix:JR
Authorized Official - Credentials:OD
Authorized Official - Phone:850-240-2021
Mailing Address - Street 1:PO BOX 5836
Mailing Address - Street 2:
Mailing Address - City:DESTIN
Mailing Address - State:FL
Mailing Address - Zip Code:32540-5836
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:300 MARY ESTHER BLVD
Practice Address - Street 2:STE. #47
Practice Address - City:MARY ESTHER
Practice Address - State:FL
Practice Address - Zip Code:32569-1693
Practice Address - Country:US
Practice Address - Phone:850-664-6339
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-03
Last Update Date:2012-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC2570152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLU59951Medicare UPIN
FL20654AMedicare PIN