Healthcare Provider Details

I. General information

NPI: 1275714164
Provider Name (Legal Business Name): MS. CARLOTTA LEWIS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/19/2007
Last Update Date: 11/19/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3055 W RAMSEY ST
BANNING CA
92220-3781
US

IV. Provider business mailing address

4065 COUNTY CIRCLE DR
RIVERSIDE CA
92503-3410
US

V. Phone/Fax

Practice location:
  • Phone: 951-922-1624
  • Fax: 951-922-1625
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC1500X
TaxonomyCommunity Health Registered Nurse
License Number511366
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: