Basic Information
| Provider Information | |||||||||
| NPI: | 1962440404 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOARD | ||||||||
| FirstName: | LYLE | ||||||||
| MiddleName: | EVERETT | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | ATC, CSCS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8080 BLUEBONNET BLVD | ||||||||
| Address2: | |||||||||
| City: | BATON ROUGE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 708107827 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2254087990 | ||||||||
| FaxNumber: | 2254087989 | ||||||||
| Practice Location | |||||||||
| Address1: | 8080 BLUEBONNET BLVD | ||||||||
| Address2: | |||||||||
| City: | BATON ROUGE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 708107827 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2254087990 | ||||||||
| FaxNumber: | 2254087989 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/04/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225500000X | J00203 | LA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Specialist/Technologist |
ID Information
| ID | Type | State | Issuer | Description | J00203 | 01 | LA | STATE LICENSE | OTHER |