Provider Demographics
NPI:1154377596
Name:LUCAS PHYSICAL THERAPY AND FITNESS INC
Entity type:Organization
Organization Name:LUCAS PHYSICAL THERAPY AND FITNESS INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROLAND
Authorized Official - Middle Name:N
Authorized Official - Last Name:LUCAS
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:408-774-1424
Mailing Address - Street 1:1322 S MARY AVE
Mailing Address - Street 2:
Mailing Address - City:SUNNYVALE
Mailing Address - State:CA
Mailing Address - Zip Code:94087-3165
Mailing Address - Country:US
Mailing Address - Phone:408-774-1424
Mailing Address - Fax:408-774-0851
Practice Address - Street 1:1322 S MARY AVE
Practice Address - Street 2:
Practice Address - City:SUNNYVALE
Practice Address - State:CA
Practice Address - Zip Code:94087-3165
Practice Address - Country:US
Practice Address - Phone:408-774-1424
Practice Address - Fax:408-774-0851
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-26
Last Update Date:2009-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QP2000X
CA261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ26149ZMedicare PIN