Basic Information
Provider Information | |||||||||
NPI: | 1639305261 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ROBERTS | ||||||||
FirstName: | LEWIS | ||||||||
MiddleName: | WESLEY | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | CRT | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2709 ROPER DR | ||||||||
Address2: |   | ||||||||
City: | PLANO | ||||||||
State: | TX | ||||||||
PostalCode: | 750252410 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9037180863 | ||||||||
FaxNumber: | 9035321401 | ||||||||
Practice Location | |||||||||
Address1: | 8001 S US HWY 75 | ||||||||
Address2: |   | ||||||||
City: | SHERMAN | ||||||||
State: | TX | ||||||||
PostalCode: | 750905707 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9037180863 | ||||||||
FaxNumber: | 9035321401 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/10/2009 | ||||||||
LastUpdateDate: | 06/10/2009 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2278H0200X | 59530 | TX | Y |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Respiratory Therapist, Certified | Home Health |
ID Information
ID | Type | State | Issuer | Description | 59530 | 01 | TX | RESPIRATORY CARE PRACTITIONER | OTHER |