Basic Information
| Provider Information | |||||||||
| NPI: | 1417079989 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LUCERO | ||||||||
| FirstName: | KENNETH | ||||||||
| MiddleName: | GRANT | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 205 N 1ST ST | ||||||||
| Address2: | SUITE A | ||||||||
| City: | BLYTHE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 922251777 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7609213468 | ||||||||
| FaxNumber: | 7609213471 | ||||||||
| Practice Location | |||||||||
| Address1: | 321 W HOBSONWAY STE C | ||||||||
| Address2: | |||||||||
| City: | BLYTHE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 922251651 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7609224981 | ||||||||
| FaxNumber: | 7609224442 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/04/2007 | ||||||||
| LastUpdateDate: | 08/03/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 08/03/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | G60508 | CA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 00G605082 | 05 | CA | MEDICAID |