1558911883 NPI number — MR. JOSEPH LEITH ANTHONY LEWIS RBT

Table of content: MR. JOSEPH LEITH ANTHONY LEWIS RBT (NPI 1558911883)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558911883 NPI number — MR. JOSEPH LEITH ANTHONY LEWIS RBT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LEWIS
Provider First Name:
JOSEPH
Provider Middle Name:
LEITH ANTHONY
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
RBT
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1558911883
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/18/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1510 WINDWOOD DR NE APT 103
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PALM BAY
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32905-7592
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
321-720-5941
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
130 N TROPICAL TRL
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MERRITT ISLAND
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32953-4737
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
321-961-7831
Provider Business Practice Location Address Fax Number:
407-960-3009
Provider Enumeration Date:
09/18/2019

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: 103K00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 104238300 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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