Provider Demographics
NPI:1154095180
Name:LUCKAS, NATHAN JAMES
Entity Type:Individual
Prefix:
First Name:NATHAN
Middle Name:JAMES
Last Name:LUCKAS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:44562 BAYVIEW AVE APT 13112
Mailing Address - Street 2:
Mailing Address - City:CLINTON TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48038-7057
Mailing Address - Country:US
Mailing Address - Phone:586-601-6244
Mailing Address - Fax:
Practice Address - Street 1:1685 BALDWIN AVE STE 100
Practice Address - Street 2:
Practice Address - City:PONTIAC
Practice Address - State:MI
Practice Address - Zip Code:48340-1242
Practice Address - Country:US
Practice Address - Phone:248-706-3450
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-03
Last Update Date:2021-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator