Healthcare Provider Details

I. General information

NPI: 1700791274
Provider Name (Legal Business Name): LUCAS JOHN LLEWELLYN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/18/2026
Last Update Date: 08/19/2026
Certification Date: 08/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 N NORMA ST
RIDGECREST CA
93555-2575
US

IV. Provider business mailing address

6542 RIDGECREST BLVD
INYOKERN CA
93527-2440
US

V. Phone/Fax

Practice location:
  • Phone: 760-793-7580
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License NumberMPSS-NGJTWL
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: