Basic Information
| Provider Information | |||||||||
| NPI: | 1912639642 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | KENNETH C. LEWIS MD,LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8524 W GAGE BLVD # 319 | ||||||||
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| City: | KENNEWICK | ||||||||
| State: | WA | ||||||||
| PostalCode: | 993368241 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 201 W PARK DR | ||||||||
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| City: | GRAND JUNCTION | ||||||||
| State: | CO | ||||||||
| PostalCode: | 815051469 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5095910070 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/30/2022 | ||||||||
| LastUpdateDate: | 06/30/2022 | ||||||||
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| AuthorizedOfficialLastName: | JOHNS | ||||||||
| AuthorizedOfficialFirstName: | DEBBIE | ||||||||
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| AuthorizedOfficialTitleorPosition: | CREDENTIALER | ||||||||
| AuthorizedOfficialTelephone: | 9702541686 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 06/30/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP3300X | N | Ambulatory Health Care Facilities | Clinic/Center | Pain | 207LP2900X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1092681 | 05 | CO | MEDICAID |