Provider Demographics
NPI:1073980934
Name:LUCAS, CODY (ATC)
Entity Type:Individual
Prefix:
First Name:CODY
Middle Name:
Last Name:LUCAS
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4203 CASA BLVD
Mailing Address - Street 2:
Mailing Address - City:GROVE CITY
Mailing Address - State:OH
Mailing Address - Zip Code:43123-3424
Mailing Address - Country:US
Mailing Address - Phone:614-634-8608
Mailing Address - Fax:
Practice Address - Street 1:300 COLLEGE PARK AVE
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45469-0001
Practice Address - Country:US
Practice Address - Phone:937-229-4437
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-26
Last Update Date:2015-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH0043952255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer