Basic Information
| Provider Information | |||||||||
| NPI: | 1649944018 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LEAL | ||||||||
| FirstName: | LUCAS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7505 N LOOP 1604 E STE 101 | ||||||||
| Address2: | |||||||||
| City: | LIVE OAK | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782332604 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2105904000 | ||||||||
| FaxNumber: | 2105904585 | ||||||||
| Practice Location | |||||||||
| Address1: | 11909 PRESTON RD STE 1482 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752306114 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2144461601 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/09/2021 | ||||||||
| LastUpdateDate: | 08/09/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/09/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 1348949 | 01 | TX | PT LICENSE | OTHER |