Healthcare Provider Details

I. General information

NPI: 1144641036
Provider Name (Legal Business Name): LUCAS REID BOPP DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/19/2013
Last Update Date: 06/24/2020
Certification Date: 06/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

132 4TH AVE NE
VALLEY CITY ND
58072-3056
US

IV. Provider business mailing address

PO BOX 6001
FARGO ND
58108-6001
US

V. Phone/Fax

Practice location:
  • Phone: 701-845-8060
  • Fax:
Mailing address:
  • Phone: 701-364-3300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number1700
License Number StateND

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: