MEDICARE: MRS. CAROL ALTHEA LEWIS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	311ZA0620X	Adult Care Home Facility	6905687	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1326485186
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. CAROL ALTHEA LEWIS

Provider Business Mailing Address
First Line	:	12101 RONDA LN
Second Line	:
City	:	NORTH PORT
State	:	FL
Zip	:	34287-1468
Country	:	US
Telephone Number	:	941-426-7707
Fax Number	:	941-426-7707

Provider Business Practice Location Address
First Line	:	12101 RONDA LN
Second Line	:
City	:	NORTH PORT
State	:	FL
Zip	:	34287-1468
Country	:	US
Telephone Number	:	941-426-7707
Fax Number	:	941-426-7707

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/03/2013
Last Update Date	:	06/03/2013

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