MEDICARE: LUCAS BIANCO ATC, CSCS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2255A2300X	Athletic Trainer	0506296	NV

General Provider Information

NPI Number	:	1114348968
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LUCAS BIANCO ATC, CSCS

Provider Business Mailing Address
First Line	:	3601 CAMBRIDGE ST APT 149
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89169-4010
Country	:	US
Telephone Number	:	845-728-4176
Fax Number	:

Provider Business Practice Location Address
First Line	:	3601 CAMBRIDGE ST APT 149
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89169-4010
Country	:	US
Telephone Number	:	845-728-4176
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/20/2013
Last Update Date	:	12/20/2013

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