Healthcare Provider Details

I. General information

NPI: 1275649436
Provider Name (Legal Business Name): LEWIS GROVE D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/21/2006
Last Update Date: 08/01/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3000 NORTH LAKE BLVD. SUITE 4
TAHOE CITY CA
96145
US

IV. Provider business mailing address

PO BOX 1286
TAHOE CITY CA
96145-1286
US

V. Phone/Fax

Practice location:
  • Phone: 530-583-2225
  • Fax: 801-382-6066
Mailing address:
  • Phone: 530-583-2225
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberDC 23161
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: