Provider Demographics
NPI:1215588454
Name:LUCIOUS, IRENE FAY
Entity Type:Individual
Prefix:
First Name:IRENE
Middle Name:FAY
Last Name:LUCIOUS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14072 MARE LN
Mailing Address - Street 2:
Mailing Address - City:VICTORVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:92394-7527
Mailing Address - Country:US
Mailing Address - Phone:760-403-6079
Mailing Address - Fax:
Practice Address - Street 1:14072 MARE LN
Practice Address - Street 2:
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92394-7527
Practice Address - Country:US
Practice Address - Phone:760-403-6079
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-27
Last Update Date:2019-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider