=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134329642
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CANDACE LEWIS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/23/2007
-----------------------------------------------------
Last Update Date | 07/23/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 211 BLANCHARD AVENUE
-----------------------------------------------------
City | MTN. VIEW
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72560
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 870-269-8100
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2083 OAK HILL LOOP
-----------------------------------------------------
City | BATESVILLE
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72501-8710
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 870-834-7959
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171M00000X
-----------------------------------------------------
Taxonomy Name | Case Manager/Care Coordinator
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------