1053970335 NPI number — DR. LUCAS LIN CHANG PT, DPT, CSCS

Table of content: DR. LUCAS LIN CHANG PT, DPT, CSCS (NPI 1053970335)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053970335 NPI number — DR. LUCAS LIN CHANG PT, DPT, CSCS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CHANG
Provider First Name:
LUCAS
Provider Middle Name:
LIN
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PT, DPT, CSCS
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1053970335
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/21/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2240 GREENSPRING DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TIMONIUM
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21093-3114
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
410-989-3833
Provider Business Mailing Address Fax Number:
443-842-5766

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9030 STATE ROUTE 108 STE B
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COLUMBIA
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21045-1990
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-989-3833
Provider Business Practice Location Address Fax Number:
443-842-5766
Provider Enumeration Date:
06/10/2019

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2251X0800X , with the licence number:  27504 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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