Provider Demographics
NPI:1023467917
Name:POLLEY, LUCAS
Entity type:Individual
Prefix:
First Name:LUCAS
Middle Name:
Last Name:POLLEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:134 MAYNARD DR
Mailing Address - Street 2:APT. A
Mailing Address - City:TIPP CITY
Mailing Address - State:OH
Mailing Address - Zip Code:45371-1579
Mailing Address - Country:US
Mailing Address - Phone:937-876-9833
Mailing Address - Fax:
Practice Address - Street 1:2400 MIAMI VALLEY DR
Practice Address - Street 2:SPORTS MEDICINE CETER
Practice Address - City:CENTERVILLE
Practice Address - State:OH
Practice Address - Zip Code:45459-4774
Practice Address - Country:US
Practice Address - Phone:937-876-9833
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-10
Last Update Date:2016-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH0044112255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer