Healthcare Provider Details

I. General information

NPI: 1851855282
Provider Name (Legal Business Name): LUCAS ISLEY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/30/2019
Last Update Date: 07/15/2021
Certification Date: 07/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3096 POPLAR AVE
MEMPHIS TN
38111-3532
US

IV. Provider business mailing address

PO BOX 306393
NASHVILLE TN
37230-6393
US

V. Phone/Fax

Practice location:
  • Phone: 901-203-6366
  • Fax: 901-746-0410
Mailing address:
  • Phone: 615-373-1350
  • Fax: 615-221-9054

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number11783
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: