Provider Demographics
NPI:1942953054
Name:LEWIS, LUCKY JR
Entity type:Individual
Prefix:
First Name:LUCKY
Middle Name:
Last Name:LEWIS
Suffix:JR
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 1:4300 OLD SCIOTO TRL
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:OH
Mailing Address - Zip Code:45662-6642
Mailing Address - Country:US
Mailing Address - Phone:740-285-6944
Mailing Address - Fax:
Practice Address - Street 1:4300 OLD SCIOTO TRL
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:OH
Practice Address - Zip Code:45662-6642
Practice Address - Country:US
Practice Address - Phone:740-351-9298
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-28
Last Update Date:2022-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes175T00000XOther Service ProvidersPeer SpecialistGroup - Single Specialty