Provider Demographics
NPI:1104194901
Name:THEA C LEWIS DC LLC
Entity Type:Organization
Organization Name:THEA C LEWIS DC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:THEA
Authorized Official - Middle Name:C
Authorized Official - Last Name:LEWIS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:313-724-1792
Mailing Address - Street 1:22190 GARRISON ST
Mailing Address - Street 2:202
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48124-2260
Mailing Address - Country:US
Mailing Address - Phone:313-724-1792
Mailing Address - Fax:
Practice Address - Street 1:22190 GARRISON ST
Practice Address - Street 2:202
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48124-2260
Practice Address - Country:US
Practice Address - Phone:313-724-1792
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-07
Last Update Date:2011-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301007082111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty