Healthcare Provider Details

I. General information

NPI: 1265795066
Provider Name (Legal Business Name): ROBERTA LEWIS L.AC.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/18/2012
Last Update Date: 06/18/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1834 DWIGHT WAY
BERKELEY CA
94703-1924
US

IV. Provider business mailing address

36 BAYSIDE CT
RICHMOND CA
94804-7442
US

V. Phone/Fax

Practice location:
  • Phone: 510-540-8528
  • Fax:
Mailing address:
  • Phone: 510-778-1979
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberAC3390
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: