Provider Demographics
NPI:1609439272
Name:LYLES, OTIS D JR
Entity Type:Individual
Prefix:
First Name:OTIS
Middle Name:D
Last Name:LYLES
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:305 LYNN DR
Mailing Address - Street 2:
Mailing Address - City:ALTON
Mailing Address - State:IL
Mailing Address - Zip Code:62002-7508
Mailing Address - Country:US
Mailing Address - Phone:314-581-7735
Mailing Address - Fax:
Practice Address - Street 1:305 LYNN DR
Practice Address - Street 2:
Practice Address - City:ALTON
Practice Address - State:IL
Practice Address - Zip Code:62002-7508
Practice Address - Country:US
Practice Address - Phone:314-581-7735
Practice Address - Fax:618-466-5501
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-18
Last Update Date:2019-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)