Provider Demographics
NPI:1639265952
Name:LEWIS, CLAYTON ROY (DC)
Entity Type:Individual
Prefix:DR
First Name:CLAYTON
Middle Name:ROY
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 1:711 3RD ST
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MN
Mailing Address - Zip Code:56143-1614
Mailing Address - Country:US
Mailing Address - Phone:507-847-4390
Mailing Address - Fax:
Practice Address - Street 1:711 3RD ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MN
Practice Address - Zip Code:56143-1614
Practice Address - Country:US
Practice Address - Phone:507-847-4390
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2042111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NS0005XChiropractic ProvidersChiropractorSports Physician
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN455727100Medicaid
MN455727100Medicaid
MN300021917OtherEIN
MN455727100Medicaid