Healthcare Provider Details

I. General information

NPI: 1760115513
Provider Name (Legal Business Name): THOMAS M. LUCAS IV, O.D., INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/07/2022
Last Update Date: 05/29/2024
Certification Date: 07/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

112 W 1ST ST
CLOVERDALE CA
95425-3607
US

IV. Provider business mailing address

112 W 1ST ST
CLOVERDALE CA
95425-3607
US

V. Phone/Fax

Practice location:
  • Phone: 707-894-3936
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State

VIII. Authorized Official

Name: DR. THOMAS LUCAS IV
Title or Position: CEO
Credential: OD
Phone: 209-534-0734