Healthcare Provider Details

I. General information

NPI: 1629489471
Provider Name (Legal Business Name): JOHN LEWIS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/14/2014
Last Update Date: 05/14/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

744 E SWON AVE
SAINT LOUIS MO
63119-4228
US

IV. Provider business mailing address

PO BOX 190128
SAINT LOUIS MO
63119-6128
US

V. Phone/Fax

Practice location:
  • Phone: 877-996-9677
  • Fax:
Mailing address:
  • Phone: 877-996-9677
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: