Healthcare Provider Details

I. General information

NPI: 1912639642
Provider Name (Legal Business Name): KENNETH C. LEWIS MD,LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/30/2022
Last Update Date: 06/30/2022
Certification Date: 06/30/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 W PARK DR
GRAND JUNCTION CO
81505-1469
US

IV. Provider business mailing address

8524 W GAGE BLVD # 319
KENNEWICK WA
99336-8241
US

V. Phone/Fax

Practice location:
  • Phone: 509-591-0070
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QP3300X
TaxonomyPain Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DEBBIE JOHNS
Title or Position: CREDENTIALER
Credential:
Phone: 970-254-1686