=====================================================
General NPI Number Information
=====================================================
NPI Number | 1740705847
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ERIC FORTUNE LUKENS MOT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/09/2017
-----------------------------------------------------
Last Update Date | 08/09/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3000 BALFOUR CIR
-----------------------------------------------------
City | PHOENIXVILLE
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19460-2144
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 610-726-1286
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4032 PILGRIM RD
-----------------------------------------------------
City | PLYMOUTH MEETING
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19462-1535
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-301-1069
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225X00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapist
-----------------------------------------------------
License Number | OC015095
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------