Healthcare Provider Details

I. General information

NPI: 1902680531
Provider Name (Legal Business Name): IMANI LUCAS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/23/2023
Last Update Date: 08/11/2025
Certification Date: 08/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3810 BROADWAY
SACRAMENTO CA
95817-3302
US

IV. Provider business mailing address

3810 BROADWAY
SACRAMENTO CA
95817-3302
US

V. Phone/Fax

Practice location:
  • Phone: 800-707-3358
  • Fax:
Mailing address:
  • Phone: 562-286-1492
  • Fax: 916-312-3857

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code373H00000X
TaxonomyDay Training/Habilitation Specialist
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License NumberB5259801
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code374J00000X
TaxonomyDoula
License Number
License Number StateNULL
# 5
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: