Healthcare Provider Details

I. General information

NPI: 1295093086
Provider Name (Legal Business Name): DEMETRIUS VINDE LEWIS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/30/2012
Last Update Date: 04/30/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1314 PAGODA DR
COLUMBUS GA
31907-4439
US

IV. Provider business mailing address

1314 PAGODA DR
COLUMBUS GA
31907-4439
US

V. Phone/Fax

Practice location:
  • Phone: 706-593-8727
  • Fax:
Mailing address:
  • Phone: 706-593-8727
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code376G00000X
TaxonomyNursing Home Administrator
License NumberNIIA005224
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License NumberLPN052272
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: