Provider Demographics
NPI:1700945813
Name:LUCICH, BURTON ANTHONY (DC)
Entity Type:Individual
Prefix:
First Name:BURTON
Middle Name:ANTHONY
Last Name:LUCICH
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34189 PCH SUITE 203
Mailing Address - Street 2:
Mailing Address - City:DANA POINT
Mailing Address - State:CA
Mailing Address - Zip Code:92629
Mailing Address - Country:US
Mailing Address - Phone:949-240-6422
Mailing Address - Fax:
Practice Address - Street 1:24721 LA PLAZA
Practice Address - Street 2:
Practice Address - City:DANA POINT
Practice Address - State:CA
Practice Address - Zip Code:92629
Practice Address - Country:US
Practice Address - Phone:949-240-7423
Practice Address - Fax:949-240-6424
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-06
Last Update Date:2019-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC 24483111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC 24483Medicare UPIN
CAU63402Medicare ID - Type Unspecified