Provider Demographics
NPI:1275657710
Name:LEWIS, MALCOLM (ACUPUNCTURIST)
Entity Type:Individual
Prefix:
First Name:MALCOLM
Middle Name:
Last Name:LEWIS
Suffix:
Gender:M
Credentials:ACUPUNCTURIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 OLD MCCLOUD RD
Mailing Address - Street 2:
Mailing Address - City:MOUNT SHASTA
Mailing Address - State:CA
Mailing Address - Zip Code:96067-2796
Mailing Address - Country:US
Mailing Address - Phone:530-926-5100
Mailing Address - Fax:530-926-1859
Practice Address - Street 1:101 OLD MCCLOUD RD
Practice Address - Street 2:
Practice Address - City:MOUNT SHASTA
Practice Address - State:CA
Practice Address - Zip Code:96067-2796
Practice Address - Country:US
Practice Address - Phone:530-926-5100
Practice Address - Fax:530-926-1859
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC1037171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ28085ZOtherBLUE SHIELD