Healthcare Provider Details

I. General information

NPI: 1639265952
Provider Name (Legal Business Name): CLAYTON ROY LEWIS D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/05/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

711 3RD ST
JACKSON MN
56143-1614
US

IV. Provider business mailing address

711 3RD ST
JACKSON MN
56143-1614
US

V. Phone/Fax

Practice location:
  • Phone: 507-847-4390
  • Fax:
Mailing address:
  • Phone: 507-847-4390
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NS0005X
TaxonomySports Physician Chiropractor
License Number2042
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: