1073798252 NPI number — MRS. JENNIFER LYNN LEWIS PT, DPT, ATP

Table of content: MRS. JENNIFER LYNN LEWIS PT, DPT, ATP (NPI 1073798252)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073798252 NPI number — MRS. JENNIFER LYNN LEWIS PT, DPT, ATP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LEWIS
Provider First Name:
JENNIFER
Provider Middle Name:
LYNN
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
PT, DPT, ATP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MCLAUGHLIN
Provider Other First Name:
JENNIFER
Provider Other Middle Name:
LYNN
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PT, DPT, ATP
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1073798252
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/15/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
102 LUMBER CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MYRTLE BEACH
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29588-7438
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
843-685-7413
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
407 CHURCH ST
Provider Second Line Business Practice Location Address:
SUITE E
Provider Business Practice Location Address City Name:
GEORGETOWN
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29440-3792
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
843-545-5300
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/07/2008

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  5953 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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