Healthcare Provider Details

I. General information

NPI: 1982180634
Provider Name (Legal Business Name): GREGORY ANTHONY LUCIO JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/16/2018
Last Update Date: 02/01/2023
Certification Date: 02/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1624 SANTA CLARA DR STE 145
ROSEVILLE CA
95661-3500
US

IV. Provider business mailing address

1624 SANTA CLARA DR STE 145
ROSEVILLE CA
95661-3500
US

V. Phone/Fax

Practice location:
  • Phone: 916-779-2455
  • Fax:
Mailing address:
  • Phone: 916-779-2455
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: