Basic Information
| Provider Information | |||||||||
| NPI: | 1285774745 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LUCAS PHYSICAL THERAPY INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | LUCAS THERAPIES PC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 484 RIVERSIDE AVE | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322024912 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8006999395 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4325 BRAMBLETON AVE STE A | ||||||||
| Address2: | |||||||||
| City: | ROANOKE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 240183404 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5407728022 | ||||||||
| FaxNumber: | 5407720294 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/07/2007 | ||||||||
| LastUpdateDate: | 02/22/2022 | ||||||||
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| AuthorizedOfficialLastName: | STREETER | ||||||||
| AuthorizedOfficialFirstName: | AMANDA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9049444063 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 02/22/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225XH1200X | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | Hand | 225100000X | Y | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 193431 | 01 | VA | ANTHEM PT GROUP # | OTHER | 193442 | 01 | VA | ANTHEM PT # LOC 5 | OTHER | 249624 | 01 | VA | ANTHEM PT # LOC 6 | OTHER | 193434 | 01 | VA | ANTHEM PT # LOC 2 | OTHER | 193437 | 01 | VA | ANTHEM PT # LOC 3 | OTHER |