Provider Demographics
NPI:1437606415
Name:SOUTHERN ILLINOIS MOBILITY, LLC
Entity Type:Organization
Organization Name:SOUTHERN ILLINOIS MOBILITY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KIP
Authorized Official - Middle Name:
Authorized Official - Last Name:LYERLA
Authorized Official - Suffix:
Authorized Official - Credentials:ATP
Authorized Official - Phone:618-521-2819
Mailing Address - Street 1:1020 LYERLA LN
Mailing Address - Street 2:
Mailing Address - City:ALTO PASS
Mailing Address - State:IL
Mailing Address - Zip Code:62905-3015
Mailing Address - Country:US
Mailing Address - Phone:618-521-2819
Mailing Address - Fax:
Practice Address - Street 1:1020 LYERLA LN
Practice Address - Street 2:
Practice Address - City:ALTO PASS
Practice Address - State:IL
Practice Address - Zip Code:62905-3015
Practice Address - Country:US
Practice Address - Phone:618-521-2819
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-07
Last Update Date:2016-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment