Basic Information
| Provider Information | |||||||||
| NPI: | 1538704531 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LUCAS | ||||||||
| FirstName: | DEVON | ||||||||
| MiddleName: | EDWARD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 700 E ROUTE 66 # 36 | ||||||||
| Address2: | |||||||||
| City: | GLENDORA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917403510 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8285365179 | ||||||||
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| Practice Location | |||||||||
| Address1: | 23701 E EAST FORK RD | ||||||||
| Address2: | |||||||||
| City: | AZUSA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917021477 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6262503290 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/13/2019 | ||||||||
| LastUpdateDate: | 01/10/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 01/10/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | Y | Other Service Providers | Case Manager/Care Coordinator |
No ID Information.