Provider Demographics
NPI:1376265041
Name:LEWIS, KEITH MAURICE JR
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:MAURICE
Last Name:LEWIS
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4530 FORSYTHE AVE
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45406-3207
Mailing Address - Country:US
Mailing Address - Phone:937-251-1865
Mailing Address - Fax:
Practice Address - Street 1:4530 FORSYTHE AVE
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45406-3207
Practice Address - Country:US
Practice Address - Phone:937-251-1865
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-19
Last Update Date:2022-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker