Provider Demographics
NPI:1346328309
Name:LUCAS, KELLY KATHLEEN III (DC)
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:KATHLEEN
Last Name:LUCAS
Suffix:III
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1636 N GYMKHANA ST
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92869-1032
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1500 E KATELLA AVE STE G
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92867-5093
Practice Address - Country:US
Practice Address - Phone:714-639-7654
Practice Address - Fax:714-639-8578
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC24971111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAU69529Medicare UPIN
CADC24971AMedicare ID - Type Unspecified