Provider Demographics
NPI:1689979528
Name:LEWIS, L COOPER (PT)
Entity Type:Individual
Prefix:
First Name:L
Middle Name:COOPER
Last Name:LEWIS
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:130 HILLCREST DR
Mailing Address - Street 2:
Mailing Address - City:BATESVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:38606-9311
Mailing Address - Country:US
Mailing Address - Phone:662-563-0378
Mailing Address - Fax:
Practice Address - Street 1:640 KEATING ROAD
Practice Address - Street 2:FAIRFIELD
Practice Address - City:BATESVILLE
Practice Address - State:MS
Practice Address - Zip Code:38606
Practice Address - Country:US
Practice Address - Phone:662-563-2345
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-01-25
Last Update Date:2011-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPT0819225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist