Provider Demographics
NPI:1710182068
Name:LUCERO, MICHAEL HAUTEA (PT)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:HAUTEA
Last Name:LUCERO
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1301
Mailing Address - Street 2:
Mailing Address - City:CLEMMONS
Mailing Address - State:NC
Mailing Address - Zip Code:27012-1301
Mailing Address - Country:US
Mailing Address - Phone:478-737-8726
Mailing Address - Fax:
Practice Address - Street 1:1000 SALEMTOWNE DR
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27106-3294
Practice Address - Country:US
Practice Address - Phone:336-776-2300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9853225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist