Basic Information
| Provider Information | |||||||||
| NPI: | 1801123930 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LUCAS | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | T | ||||||||
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| Credential: | CSA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1088 GRAVES RD | ||||||||
| Address2: | |||||||||
| City: | STAMPING GROUND | ||||||||
| State: | KY | ||||||||
| PostalCode: | 403799719 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2142272457 | ||||||||
| FaxNumber: | 2147640880 | ||||||||
| Practice Location | |||||||||
| Address1: | 1088 GRAVES RD | ||||||||
| Address2: | |||||||||
| City: | STAMPING GROUND | ||||||||
| State: | KY | ||||||||
| PostalCode: | 403799719 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2142272457 | ||||||||
| FaxNumber: | 2147640880 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/10/2009 | ||||||||
| LastUpdateDate: | 11/05/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 246ZC0007X | CSA3419 | KY | Y | Technologists, Technicians & Other Technical Service Providers | Specialist/Technologist, Other | Certified First Assistant |
No ID Information.