Provider Demographics
NPI:1811326069
Name:BANTUGAN, LUCILLE
Entity type:Individual
Prefix:
First Name:LUCILLE
Middle Name:
Last Name:BANTUGAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:325 DAYSPRING LN
Mailing Address - Street 2:
Mailing Address - City:HAGERSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21742-3456
Mailing Address - Country:US
Mailing Address - Phone:240-353-6882
Mailing Address - Fax:
Practice Address - Street 1:154 N ARTIZAN ST
Practice Address - Street 2:
Practice Address - City:WILLIAMSPORT
Practice Address - State:MD
Practice Address - Zip Code:21795-1104
Practice Address - Country:US
Practice Address - Phone:301-223-7971
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-11-08
Last Update Date:2019-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD24330225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD1447657507OtherNPI TYPE 2 (ORGANIZATION NPI)
MD4374045-00Medicaid
MD46-3684374OtherTAX ID
MD4374045-00Medicaid