Provider Demographics
NPI:1811473390
Name:GORE, LEWIS EDWARD III (PT, DPT)
Entity type:Individual
Prefix:DR
First Name:LEWIS
Middle Name:EDWARD
Last Name:GORE
Suffix:III
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:406 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SYLVANIA
Mailing Address - State:GA
Mailing Address - Zip Code:30467-2226
Mailing Address - Country:US
Mailing Address - Phone:843-446-2461
Mailing Address - Fax:
Practice Address - Street 1:1787 ALLENDALE FAIRFAX HWY
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:SC
Practice Address - Zip Code:29827-9133
Practice Address - Country:US
Practice Address - Phone:803-632-3421
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-17
Last Update Date:2018-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC7872225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist