Healthcare Provider Details

I. General information

NPI: 1184749475
Provider Name (Legal Business Name): CHARLES H. LEWIS JR. PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/19/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2067 W VISTA WAY
VISTA CA
92083-6031
US

IV. Provider business mailing address

849 RIO CLARO CT
OCEANSIDE CA
92057-6323
US

V. Phone/Fax

Practice location:
  • Phone: 760-631-5888
  • Fax: 760-631-5880
Mailing address:
  • Phone: 760-758-3103
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberAT5338
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: