Basic Information
| Provider Information | |||||||||
| NPI: | 1275657710 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LEWIS | ||||||||
| FirstName: | MALCOLM | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | ACUPUNCTURIST | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 101 OLD MCCLOUD RD | ||||||||
| Address2: | |||||||||
| City: | MOUNT SHASTA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 960672796 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5309265100 | ||||||||
| FaxNumber: | 5309261859 | ||||||||
| Practice Location | |||||||||
| Address1: | 101 OLD MCCLOUD RD | ||||||||
| Address2: | |||||||||
| City: | MOUNT SHASTA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 960672796 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5309265100 | ||||||||
| FaxNumber: | 5309261859 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/19/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171100000X | AC1037 | CA | Y | Other Service Providers | Acupuncturist |
ID Information
| ID | Type | State | Issuer | Description | ZZZ28085Z | 01 | CA | BLUE SHIELD | OTHER |