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General NPI Number Information
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NPI Number | 1487920443
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Entity Type | Organization
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Legal Business Name | LAKE BREEZE ENT & ALLERGY PC
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Dates
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Enumeration Date | 03/23/2012
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Last Update Date | 03/23/2012
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Provider Practice Location Address
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Address Line | 149 PLANTATION RIDGE DR SUITE 190
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City | MOORESVILLE
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State | NC
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Zip | 28117-9174
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Country | US
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Telephone | 713-818-0590
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Fax |
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Provider Business Mailing Address
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Address Line | 149 PLANTATION RIDGE DR SUITE 190
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City | MOORESVILLE
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State | NC
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Zip | 28117-9174
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Country | US
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Telephone | 713-818-0590
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | ROY SHELDON LEWIS
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Credential | M.D.
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Telephone | 713-818-0590
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Y00000X
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Taxonomy Name | Otolaryngology Physician
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License Number | 2011-01689
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License Number State | NC
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