Provider Demographics
NPI:1588950653
Name:BROADHURST, LUCAS (CPO)
Entity type:Individual
Prefix:
First Name:LUCAS
Middle Name:
Last Name:BROADHURST
Suffix:
Gender:M
Credentials:CPO
Other - Prefix:
Other - First Name:LUKE
Other - Middle Name:
Other - Last Name:BROADHURST
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CPO
Mailing Address - Street 1:1700 N CHRISMAN RD
Mailing Address - Street 2:
Mailing Address - City:TRACY
Mailing Address - State:CA
Mailing Address - Zip Code:95304-9314
Mailing Address - Country:US
Mailing Address - Phone:800-726-9180
Mailing Address - Fax:209-834-1158
Practice Address - Street 1:3001 L ST
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95816-5225
Practice Address - Country:US
Practice Address - Phone:916-706-1520
Practice Address - Fax:916-706-1551
Is Sole Proprietor?:No
Enumeration Date:2011-06-27
Last Update Date:2012-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetist
No222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotist
No225000000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotic Fitter