Provider Demographics
NPI:1275373136
Name:LYLE, HAVEN R
Entity type:Individual
Prefix:
First Name:HAVEN
Middle Name:R
Last Name:LYLE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:636 E 123RD ST
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44108-2330
Mailing Address - Country:US
Mailing Address - Phone:216-633-9795
Mailing Address - Fax:
Practice Address - Street 1:636 E 123RD ST
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44108-2330
Practice Address - Country:US
Practice Address - Phone:216-633-9795
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-29
Last Update Date:2024-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRS844348172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver