Healthcare Provider Details

I. General information

NPI: 1083758239
Provider Name (Legal Business Name): VERNELL DESHAN LUCAS D.C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/19/2007
Last Update Date: 04/29/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14051 PARAMOUNT BLVD SUITE C
PARAMOUNT CA
90723-6153
US

IV. Provider business mailing address

14051 PARAMOUNT BLVD SUITE C
PARAMOUNT CA
90723-2692
US

V. Phone/Fax

Practice location:
  • Phone: 562-630-5566
  • Fax: 562-630-5565
Mailing address:
  • Phone: 562-630-5566
  • Fax: 562-630-5565

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NR0400X
TaxonomyRehabilitation Chiropractor
License Number28257
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: