Provider Demographics
NPI:1477735694
Name:JOHN P LYLES OPTOMETRIST
Entity Type:Organization
Organization Name:JOHN P LYLES OPTOMETRIST
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:LYLES
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:270-395-8331
Mailing Address - Street 1:PO BOX 7451
Mailing Address - Street 2:
Mailing Address - City:PADUCAH
Mailing Address - State:KY
Mailing Address - Zip Code:42002-7451
Mailing Address - Country:US
Mailing Address - Phone:270-443-9904
Mailing Address - Fax:270-575-0717
Practice Address - Street 1:43 INDUSTRIAL PARKWAY
Practice Address - Street 2:
Practice Address - City:CALVERT CITY
Practice Address - State:KY
Practice Address - Zip Code:42029
Practice Address - Country:US
Practice Address - Phone:270-395-8331
Practice Address - Fax:270-395-5360
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-29
Last Update Date:2011-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1292DT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000058828OtherBCBS KY
KY0304550001Medicare NSC
KY000000058828OtherBCBS KY
KY9161501Medicare PIN