=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720427339
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LUCAS INVESTMENTS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/17/2013
-----------------------------------------------------
Last Update Date | 06/17/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8217 S 19TH WAY
-----------------------------------------------------
City | PHOENIX
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85042-6841
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 602-291-3021
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8217 S 19TH WAY
-----------------------------------------------------
City | PHOENIX
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85042-6841
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 602-291-3021
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/PRESIDENT
-----------------------------------------------------
Name | MR. MYRDALE LUCAS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 602-291-3021
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 344600000X
-----------------------------------------------------
Taxonomy Name | Taxi
-----------------------------------------------------
License Number | 39988
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------