Provider Demographics
NPI:1730831363
Name:LEWIS, JIMMY R
Entity type:Individual
Prefix:
First Name:JIMMY
Middle Name:R
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 1:2020 NORTHPARK DR STE 2D
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37604-3127
Mailing Address - Country:US
Mailing Address - Phone:423-975-5455
Mailing Address - Fax:423-390-0743
Practice Address - Street 1:401 PROMISE WAY LN
Practice Address - Street 2:
Practice Address - City:MEDINA
Practice Address - State:TN
Practice Address - Zip Code:38355-6967
Practice Address - Country:US
Practice Address - Phone:731-462-0020
Practice Address - Fax:731-435-3638
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-25
Last Update Date:2022-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000000308314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility