Healthcare Provider Details

I. General information

NPI: 1144218389
Provider Name (Legal Business Name): RYAN A LUCAS A.T.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/12/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 FODEN RD SUITE 103 WEST
SOUTH PORTLAND ME
04106-2319
US

IV. Provider business mailing address

69 EUCLID AVE
PORTLAND ME
04103-1200
US

V. Phone/Fax

Practice location:
  • Phone: 207-772-2625
  • Fax:
Mailing address:
  • Phone: 207-831-7540
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT190
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: