Provider Demographics
NPI:1699052274
Name:LEW, ROBERTA (LAC)
Entity type:Individual
Prefix:
First Name:ROBERTA
Middle Name:
Last Name:LEW
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 9990
Mailing Address - Street 2:
Mailing Address - City:TRUCKEE
Mailing Address - State:CA
Mailing Address - Zip Code:96162-7990
Mailing Address - Country:US
Mailing Address - Phone:530-412-3209
Mailing Address - Fax:530-582-1370
Practice Address - Street 1:11890 DONNER PASS RD
Practice Address - Street 2:SUITE #1
Practice Address - City:TRUCKEE
Practice Address - State:CA
Practice Address - Zip Code:96161-0448
Practice Address - Country:US
Practice Address - Phone:530-412-3209
Practice Address - Fax:530-582-1370
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-09
Last Update Date:2011-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC3389171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist