Healthcare Provider Details

I. General information

NPI: 1831720184
Provider Name (Legal Business Name): MARGO D LEWIS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/27/2020
Last Update Date: 01/27/2020
Certification Date: 01/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

385 LEONARD ST NE
GRAND RAPIDS MI
49503-1129
US

IV. Provider business mailing address

385 LEONARD ST NE
GRAND RAPIDS MI
49503-1129
US

V. Phone/Fax

Practice location:
  • Phone: 704-919-8275
  • Fax:
Mailing address:
  • Phone: 616-454-4777
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number4703113414
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: