Provider Demographics
NPI:1639896624
Name:MAZE, LUCKY (DPT)
Entity Type:Individual
Prefix:
First Name:LUCKY
Middle Name:
Last Name:MAZE
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2011 BLOSSOM RUN
Mailing Address - Street 2:
Mailing Address - City:SPRING HILL
Mailing Address - State:TN
Mailing Address - Zip Code:37174-4542
Mailing Address - Country:US
Mailing Address - Phone:615-913-6862
Mailing Address - Fax:
Practice Address - Street 1:18943 VICKIE AVE APT 82
Practice Address - Street 2:
Practice Address - City:CERRITOS
Practice Address - State:CA
Practice Address - Zip Code:90703-6230
Practice Address - Country:US
Practice Address - Phone:615-913-6862
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-20
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist