Basic Information
| Provider Information | |||||||||
| NPI: | 1699393819 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LINGLE | ||||||||
| FirstName: | JON | ||||||||
| MiddleName: | MICHAEL | ||||||||
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| Credential: | ATP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4709 STRATFORD DR | ||||||||
| Address2: | |||||||||
| City: | TYLER | ||||||||
| State: | TX | ||||||||
| PostalCode: | 757031535 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9032165053 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1003 N NORTHEAST LOOP 323 | ||||||||
| Address2: | |||||||||
| City: | TYLER | ||||||||
| State: | TX | ||||||||
| PostalCode: | 757082014 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9033523788 | ||||||||
| FaxNumber: | 9032557830 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/14/2020 | ||||||||
| LastUpdateDate: | 07/15/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 07/15/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225CA2500X | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Rehabilitation Counselor | Assistive Technology Supplier | 247200000X | Y | Technologists, Technicians & Other Technical Service Providers | Technician, Other |
No ID Information.