1205666740 NPI number — TIMOTHY FRANCIS LUCID V MHC-LP

Table of content: TIMOTHY FRANCIS LUCID V MHC-LP (NPI 1205666740)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205666740 NPI number — TIMOTHY FRANCIS LUCID V MHC-LP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LUCID
Provider First Name:
TIMOTHY
Provider Middle Name:
FRANCIS
Provider Name Prefix Text:
Provider Name Suffix Text:
V
Provider Credential Text:
MHC-LP
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:
1205666740
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/07/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
29 E CAYUGA ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OSWEGO
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
13126-1241
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
315-326-4100
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
522 S 4TH ST STE 200
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FULTON
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
13069-2941
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
315-598-7400
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/07/2024

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: 101YM0800X , with the licence number:  18-P130220-01 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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