Provider Demographics
NPI:1922632207
Name:LEWIS, JIMMY
Entity Type:Individual
Prefix:
First Name:JIMMY
Middle Name:
Last Name:LEWIS
Suffix:
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:PO BOX 241
Mailing Address - Street 2:
Mailing Address - City:SILOAM SPRINGS
Mailing Address - State:AR
Mailing Address - Zip Code:72761-0241
Mailing Address - Country:US
Mailing Address - Phone:918-422-0028
Mailing Address - Fax:918-422-0027
Practice Address - Street 1:399 TILLERY LN
Practice Address - Street 2:
Practice Address - City:WATTS
Practice Address - State:OK
Practice Address - Zip Code:74964-5072
Practice Address - Country:US
Practice Address - Phone:918-422-0028
Practice Address - Fax:918-422-0027
Is Sole Proprietor?:No
Enumeration Date:2020-02-26
Last Update Date:2020-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver