Healthcare Provider Details

I. General information

NPI: 1972555969
Provider Name (Legal Business Name): LEWIS J SIMON KINESIOTHERAPIST
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/17/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3701 LOOP RD
TUSCALOOSA AL
35404-5015
US

IV. Provider business mailing address

7124 LAUREL WOOD DR 3701 LOOP ROAD EAST
TUSCALOOSA AL
35405-6753
US

V. Phone/Fax

Practice location:
  • Phone: 205-554-3780
  • Fax: 205-554-2042
Mailing address:
  • Phone: 205-759-1815
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code226300000X
TaxonomyKinesiotherapist
License Number1239
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: