Provider Demographics
NPI:1699733063
Name:MYERS, LUCAS MICHAEL (PT ATC CSCS)
Entity type:Individual
Prefix:MR
First Name:LUCAS
Middle Name:MICHAEL
Last Name:MYERS
Suffix:
Gender:M
Credentials:PT ATC CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:630-296-2223
Mailing Address - Fax:630-759-3251
Practice Address - Street 1:11223 W 22ND ST
Practice Address - Street 2:
Practice Address - City:WESTCHESTER
Practice Address - State:IL
Practice Address - Zip Code:60154-5706
Practice Address - Country:US
Practice Address - Phone:708-483-0005
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-03
Last Update Date:2014-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070012579225100000X
IL0960016172255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILF400169081Medicare PIN
ILK04706Medicare ID - Type UnspecifiedKENDALL COUNTY
ILK53175Medicare PIN
ILIL2993005Medicare PIN
ILL87353Medicare ID - Type UnspecifiedCOOK COUNTY
ILK48268Medicare PIN
ILL87354Medicare ID - Type UnspecifiedDUPAGE WILL COUNTY
ILK53174Medicare PIN