MEDICARE: MARK LUCKENBACK

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	246Z00000X	Other Specialist/Technologist	TT10397	FL

General Provider Information

NPI Number	:	1326066416
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARK LUCKENBACK

Provider Business Mailing Address
First Line	:	PO BOX 8135
Second Line	:
City	:	SEBRING
State	:	FL
Zip	:	33872-0119
Country	:	US
Telephone Number	:	863-386-1599
Fax Number	:	863-386-1699

Provider Business Practice Location Address
First Line	:	1751 US HIGHWAY 27 S
Second Line	:
City	:	SEBRING
State	:	FL
Zip	:	33870-4920
Country	:	US
Telephone Number	:	863-386-1599
Fax Number	:	863-386-1699

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/17/2006
Last Update Date	:	07/08/2007

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Directions to “ MARK LUCKENBACK ” Practice Location

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