Healthcare Provider Details

I. General information

NPI: 1073504437
Provider Name (Legal Business Name): CHARLES DERON LEWIS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/03/2005
Last Update Date: 05/11/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

310 N ADAMS STREET
CARTHAGE TX
75633
US

IV. Provider business mailing address

PO BOX 187
CARTHAGE TX
75633
US

V. Phone/Fax

Practice location:
  • Phone: 903-694-2285
  • Fax: 903-694-9658
Mailing address:
  • Phone: 903-694-2285
  • Fax: 903-694-9658

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: MR. CHARLES DERON LEWIS
Title or Position: OWNER/PROPRIETOR
Credential:
Phone: 903-694-2285