MEDICARE: LUCAS RANDALL PERRY

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	133V00000X	Registered Dietitian

General Provider Information

NPI Number	:	1912629163
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LUCAS RANDALL PERRY

Provider Business Mailing Address
First Line	:	5263 S COMMERCE DR STE 201
Second Line	:
City	:	MURRAY
State	:	UT
Zip	:	84107-5306
Country	:	US
Telephone Number	:	801-274-3392
Fax Number	:

Provider Business Practice Location Address
First Line	:	5263 S COMMERCE DR STE 201
Second Line	:
City	:	MURRAY
State	:	UT
Zip	:	84107-5306
Country	:	US
Telephone Number	:	801-274-3392
Fax Number	:

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

Provider Enumeration Date	:	09/14/2022
Last Update Date	:	09/14/2022

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Directions to “ LUCAS RANDALL PERRY ” Practice Location

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