Provider Demographics
NPI:1326485186
Name:LEWIS, CAROL ALTHEA
Entity Type:Individual
Prefix:MRS
First Name:CAROL
Middle Name:ALTHEA
Last Name:LEWIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12101 RONDA LN
Mailing Address - Street 2:
Mailing Address - City:NORTH PORT
Mailing Address - State:FL
Mailing Address - Zip Code:34287-1468
Mailing Address - Country:US
Mailing Address - Phone:941-426-7707
Mailing Address - Fax:941-426-7707
Practice Address - Street 1:12101 RONDA LN
Practice Address - Street 2:
Practice Address - City:NORTH PORT
Practice Address - State:FL
Practice Address - Zip Code:34287-1468
Practice Address - Country:US
Practice Address - Phone:941-426-7707
Practice Address - Fax:941-426-7707
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-03
Last Update Date:2013-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL6905687311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1417657Medicaid