Provider Demographics
NPI:1548593239
Name:LEWIS, KEVIN DALE (DC)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:DALE
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 1:561 NE BELLEVUE DR STE 102
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97701-7696
Mailing Address - Country:US
Mailing Address - Phone:541-330-7080
Mailing Address - Fax:541-330-7081
Practice Address - Street 1:753 SW 11TH ST APT A
Practice Address - Street 2:
Practice Address - City:REDMOND
Practice Address - State:OR
Practice Address - Zip Code:97756-2632
Practice Address - Country:US
Practice Address - Phone:541-526-1488
Practice Address - Fax:541-322-6800
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-11
Last Update Date:2015-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR3952111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR1548593239OtherNPI