Healthcare Provider Details

I. General information

NPI: 1932854833
Provider Name (Legal Business Name): LUCAS BOGAN PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/18/2022
Last Update Date: 02/18/2022
Certification Date: 02/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

33900 HARPER AVE STE 104
CLINTON TWP MI
48035-4258
US

IV. Provider business mailing address

33900 HARPER AVE STE 104
CLINTON TWP MI
48035-4258
US

V. Phone/Fax

Practice location:
  • Phone: 586-350-2644
  • Fax:
Mailing address:
  • Phone: 586-350-2644
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number5502007999
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: