Provider Demographics
NPI:1225095854
Name:LEWIS, ROY (DC)
Entity Type:Individual
Prefix:DR
First Name:ROY
Middle Name:
Last Name:LEWIS
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:982 DALE ST N
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55117-5602
Mailing Address - Country:US
Mailing Address - Phone:651-488-1332
Mailing Address - Fax:
Practice Address - Street 1:982 DALE ST N
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55117-5602
Practice Address - Country:US
Practice Address - Phone:651-488-1332
Practice Address - Fax:651-488-1889
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-27
Last Update Date:2017-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3053111N00000X
MNR 201129-1163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN3C067LEOtherBLUE CROSS BLUE SHIELD
MN878528700Medicaid
MN3C067LEOtherBLUE CROSS BLUE SHIELD