Provider Demographics
NPI:1427524271
Name:LEWIS, MICHAEL RAY
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:RAY
Last Name:LEWIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:621 COUNTRY ROAD 263
Mailing Address - Street 2:
Mailing Address - City:JASPER
Mailing Address - State:TX
Mailing Address - Zip Code:75951
Mailing Address - Country:US
Mailing Address - Phone:469-265-9195
Mailing Address - Fax:
Practice Address - Street 1:2485 S MAJOR DR
Practice Address - Street 2:
Practice Address - City:BEAUMONT
Practice Address - State:TX
Practice Address - Zip Code:77707-5019
Practice Address - Country:US
Practice Address - Phone:409-861-4611
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-19
Last Update Date:2018-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2143125225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant