Healthcare Provider Details

I. General information

NPI: 1831604909
Provider Name (Legal Business Name): MARY ELIZABETH LEWIS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/11/2017
Last Update Date: 12/11/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 FAIRFOREST RD
COLUMBIA SC
29212-2308
US

IV. Provider business mailing address

1212 METZE RD APT 12D
COLUMBIA SC
29210-0751
US

V. Phone/Fax

Practice location:
  • Phone: 803-404-9300
  • Fax:
Mailing address:
  • Phone: 803-404-9300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1744P3200X
TaxonomyProsthetics Case Management
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: