Healthcare Provider Details

I. General information

NPI: 1770088809
Provider Name (Legal Business Name): LUCAS GRAHAM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/29/2018
Last Update Date: 03/29/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3532 MONROE ST
RIVERSIDE CA
92504-6322
US

IV. Provider business mailing address

1461 LAURELWOOD CIR
CORONA CA
92882-8723
US

V. Phone/Fax

Practice location:
  • Phone: 951-687-4610
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: