MEDICARE: LUIS LUCENA

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	225200000X	Physical Therapy Assistant	2083935	TX

General Provider Information

NPI Number	:	1275959298
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LUIS LUCENA

Provider Business Mailing Address
First Line	:	1406 GOLIAD ST
Second Line	:
City	:	TYLER
State	:	TX
Zip	:	75701-7500
Country	:	US
Telephone Number	:	903-363-3279
Fax Number	:

Provider Business Practice Location Address
First Line	:	100 E FERGUSON ST
Second Line	:
City	:	TYLER
State	:	TX
Zip	:	75702-5759
Country	:	US
Telephone Number	:	903-590-2040
Fax Number	:

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

Provider Enumeration Date	:	03/14/2014
Last Update Date	:	03/14/2014

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Directions to “ LUIS LUCENA ” Practice Location

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