Healthcare Provider Details

I. General information

NPI: 1740938786
Provider Name (Legal Business Name): LUCILLE LORE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/17/2022
Last Update Date: 03/29/2022
Certification Date: 03/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

131 CEDAR ST
CENTEREACH NY
11720-3822
US

IV. Provider business mailing address

131 CEDAR ST
CENTEREACH NY
11720-3822
US

V. Phone/Fax

Practice location:
  • Phone: 631-972-5997
  • Fax:
Mailing address:
  • Phone: 631-972-5997
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QP3300X
TaxonomyPain Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: LUCILLE LORE
Title or Position: OWNER
Credential: NP
Phone: 631-972-5997