Healthcare Provider Details

I. General information

NPI: 1730527706
Provider Name (Legal Business Name): LUCAS DWAYNE DARGO ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/11/2013
Last Update Date: 06/11/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4121 W PICKELL ST
MUNCIE IN
47303-9344
US

IV. Provider business mailing address

4121 W PICKELL ST
MUNCIE IN
47303-9344
US

V. Phone/Fax

Practice location:
  • Phone: 765-716-9272
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174H00000X
TaxonomyHealth Educator
License Number10067876
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: