Provider Demographics
NPI:1740393974
Name:BLAYLOCK, LYLE JAMES (CNIM)
Entity Type:Individual
Prefix:
First Name:LYLE
Middle Name:JAMES
Last Name:BLAYLOCK
Suffix:
Gender:M
Credentials:CNIM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1819 JAY ELL DR
Mailing Address - Street 2:
Mailing Address - City:RICHARDSON
Mailing Address - State:TX
Mailing Address - Zip Code:75081-1837
Mailing Address - Country:US
Mailing Address - Phone:888-344-2947
Mailing Address - Fax:888-694-2947
Practice Address - Street 1:1819 JAY ELL DR
Practice Address - Street 2:
Practice Address - City:RICHARDSON
Practice Address - State:TX
Practice Address - Zip Code:75081-1837
Practice Address - Country:US
Practice Address - Phone:888-344-2947
Practice Address - Fax:888-694-2947
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-15
Last Update Date:2019-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1336246ZE0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZE0600XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherElectroneurodiagnostic
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX337550Medicare PIN