Provider Demographics
NPI:1134636491
Name:LYNLEY E ATWOOD, LLC
Entity Type:Organization
Organization Name:LYNLEY E ATWOOD, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:LYNLEY
Authorized Official - Middle Name:E
Authorized Official - Last Name:ATWOOD
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:618-377-5221
Mailing Address - Street 1:422 W BETHALTO DR
Mailing Address - Street 2:
Mailing Address - City:BETHALTO
Mailing Address - State:IL
Mailing Address - Zip Code:62010-1910
Mailing Address - Country:US
Mailing Address - Phone:618-377-5221
Mailing Address - Fax:
Practice Address - Street 1:422 W BETHALTO DR
Practice Address - Street 2:
Practice Address - City:BETHALTO
Practice Address - State:IL
Practice Address - Zip Code:62010
Practice Address - Country:US
Practice Address - Phone:618-377-5221
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-08
Last Update Date:2018-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046.011008152W00000X
IL046.007313152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty