Healthcare Provider Details

I. General information

NPI: 1063292829
Provider Name (Legal Business Name): JOSHUA GLENN LEWIS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/29/2023
Last Update Date: 09/29/2023
Certification Date: 09/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1ST SPECIAL OPERATIONS MEDICAL GROUP
HURLBURT FIELD FL
32544
US

IV. Provider business mailing address

520 PROMISE LAND RD
CHARLOTTE TN
37036-5405
US

V. Phone/Fax

Practice location:
  • Phone: 850-641-2337
  • Fax:
Mailing address:
  • Phone: 615-823-0721
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number1458
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: