Healthcare Provider Details

I. General information

NPI: 1265878805
Provider Name (Legal Business Name): LEWIS ENRICHMENT ADULT PROGRAM
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/21/2013
Last Update Date: 05/21/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1050 MARTIN AVE
TOLEDO OH
43612-1726
US

IV. Provider business mailing address

1050 MARTIN AVE
TOLEDO OH
43612-1726
US

V. Phone/Fax

Practice location:
  • Phone: 419-509-7143
  • Fax:
Mailing address:
  • Phone: 419-509-7143
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number State

VIII. Authorized Official

Name: MISS GLORIA KAYE LEWIS
Title or Position: CEO
Credential:
Phone: 419-509-7143