Provider Demographics
NPI:1700155876
Name:LEWIS, RAY (COTA)
Entity Type:Individual
Prefix:MR
First Name:RAY
Middle Name:
Last Name:LEWIS
Suffix:
Gender:M
Credentials:COTA
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 1157
Mailing Address - Street 2:
Mailing Address - City:CRESWELL
Mailing Address - State:OR
Mailing Address - Zip Code:97426-1157
Mailing Address - Country:US
Mailing Address - Phone:541-515-2254
Mailing Address - Fax:
Practice Address - Street 1:3329 GILLHAM RD
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64109-1780
Practice Address - Country:US
Practice Address - Phone:541-515-2254
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-20
Last Update Date:2012-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR513762251J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251J00000XAgenciesNursing Care