Basic Information
| Provider Information | |||||||||
| NPI: | 1568944692 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SHALLENBERGER | ||||||||
| FirstName: | LUCAS | ||||||||
| MiddleName: | J | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4442 5TH ST W | ||||||||
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| City: | BRADENTON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 342071531 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 6015 POINTE WEST BLVD STE 201 | ||||||||
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| City: | BRADENTON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 342095543 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9417822000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/05/2018 | ||||||||
| LastUpdateDate: | 09/03/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT33944 | FL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.