Healthcare Provider Details

I. General information

NPI: 1386116598
Provider Name (Legal Business Name): RAYMOND JAMES LUCAS CNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/28/2018
Last Update Date: 12/28/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1947 N CALIFORNIA ST STE B&C
STOCKTON CA
95204-6029
US

IV. Provider business mailing address

1947 N CALIFORNIA ST STE B&C
STOCKTON CA
95204-6029
US

V. Phone/Fax

Practice location:
  • Phone: 209-463-0870
  • Fax: 209-463-1803
Mailing address:
  • Phone: 209-463-0870
  • Fax: 209-463-1803

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code376K00000X
TaxonomyNurse's Aide
License Number00818881
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: