Healthcare Provider Details

I. General information

NPI: 1235034422
Provider Name (Legal Business Name): BROOKS RYAN LUCAS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/09/2026
Last Update Date: 10/09/2026
Certification Date: 10/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1717 S RANGE LINE RD STE 150
JOPLIN MO
64804-3234
US

IV. Provider business mailing address

508 ALEX JORDAN DR
DUENWEG MO
64841-1093
US

V. Phone/Fax

Practice location:
  • Phone: 417-556-8760
  • Fax:
Mailing address:
  • Phone: 618-731-2666
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number2024044685
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: