Provider Demographics
NPI:1093143752
Name:LEWIS BAY CHIROPRACTIC CENTER, INC
Entity Type:Organization
Organization Name:LEWIS BAY CHIROPRACTIC CENTER, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DC
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERTA
Authorized Official - Middle Name:S
Authorized Official - Last Name:WALCUTT
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:508-778-1050
Mailing Address - Street 1:83 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:HYANNIS
Mailing Address - State:MA
Mailing Address - Zip Code:02601-3134
Mailing Address - Country:US
Mailing Address - Phone:508-778-1050
Mailing Address - Fax:508-790-3966
Practice Address - Street 1:83 MAIN ST
Practice Address - Street 2:
Practice Address - City:HYANNIS
Practice Address - State:MA
Practice Address - Zip Code:02601-3134
Practice Address - Country:US
Practice Address - Phone:508-778-1050
Practice Address - Fax:508-790-3966
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-16
Last Update Date:2013-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA910111N00000X
MA909111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty