Provider Demographics
NPI:1477236867
Name:LUCAS, RUDOLPH
Entity Type:Individual
Prefix:MR
First Name:RUDOLPH
Middle Name:
Last Name:LUCAS
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 1:5658 W HARMONT DR
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85302-4669
Mailing Address - Country:US
Mailing Address - Phone:815-329-0499
Mailing Address - Fax:
Practice Address - Street 1:5658 W HARMONT DR
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85302-4669
Practice Address - Country:US
Practice Address - Phone:815-329-0499
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-10
Last Update Date:2023-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZS81862239374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide