=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376732339
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KIDS HEALTHCARE, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/16/2007
-----------------------------------------------------
Last Update Date | 01/29/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1011 W GROVE ST SUITE 120
-----------------------------------------------------
City | KAUFMAN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75142-1882
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 972-932-1319
-----------------------------------------------------
Fax | 972-932-1388
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1011 W GROVE ST SUITE 120
-----------------------------------------------------
City | KAUFMAN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75142-1882
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 972-932-1319
-----------------------------------------------------
Fax | 972-932-1388
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEDICAL DIRECTOR
-----------------------------------------------------
Name | DR. CHARLES TURNER LEWIS III
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 972-932-1319
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------