Healthcare Provider Details

I. General information

NPI: 1902528912
Provider Name (Legal Business Name): LUCAS MALONEY NGO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/15/2022
Last Update Date: 09/15/2022
Certification Date: 09/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9701 DINO DR STE 170
ELK GROVE CA
95624-4042
US

IV. Provider business mailing address

5850 GRANITE PKWY STE 600
PLANO TX
75024-6753
US

V. Phone/Fax

Practice location:
  • Phone: 916-892-0013
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: