Provider Demographics
NPI:1205851110
Name:LUCAS LODGE, LLC
Entity Type:Organization
Organization Name:LUCAS LODGE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ASSISTANT EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:LISA
Authorized Official - Middle Name:LUCAS
Authorized Official - Last Name:BURKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:757-397-8200
Mailing Address - Street 1:1214 COUNTY ST
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:VA
Mailing Address - Zip Code:23704-3240
Mailing Address - Country:US
Mailing Address - Phone:757-397-8200
Mailing Address - Fax:757-397-8224
Practice Address - Street 1:1214 COUNTY ST
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:VA
Practice Address - Zip Code:23704-3240
Practice Address - Country:US
Practice Address - Phone:757-397-8200
Practice Address - Fax:757-397-8224
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA341-01-001320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities