Provider Demographics
NPI:1215022959
Name:LUCAS, RYAN JON (DC)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:JON
Last Name:LUCAS
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 GORNICK AVE
Mailing Address - Street 2:
Mailing Address - City:GAYLORD
Mailing Address - State:MI
Mailing Address - Zip Code:49735
Mailing Address - Country:US
Mailing Address - Phone:989-732-1533
Mailing Address - Fax:989-732-0629
Practice Address - Street 1:1001 GORNICK AVE
Practice Address - Street 2:
Practice Address - City:GAYLORD
Practice Address - State:MI
Practice Address - Zip Code:49735
Practice Address - Country:US
Practice Address - Phone:989-732-1533
Practice Address - Fax:989-732-0629
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-04
Last Update Date:2012-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIRL008659111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4811820Medicaid
MI4811820Medicaid