MEDICARE: THE LUCK GROUP OUTDOORS

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	171400000X	Health & Wellness Coach

General Provider Information

NPI Number	:	1407710692
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THE LUCK GROUP OUTDOORS

Provider Business Mailing Address
First Line	:	PO BOX 1505
Second Line	:
City	:	PETERSBURG
State	:	VA
Zip	:	23805-0505
Country	:	US
Telephone Number	:	757-848-7969
Fax Number	:

Provider Business Practice Location Address
First Line	:	15265 PROVIDENCE RD
Second Line	:
City	:	SOUTH PRINCE GEORGE
State	:	VA
Zip	:	23805-8140
Country	:	US
Telephone Number	:	757-848-7969
Fax Number	:

Authorized Official
Title or Position	:	PROGRAM COORDINATOR/OWNER
Name	:	ALTHEIA TYLER
Credential	:
Telephone Number	:	757-848-7969

Provider Enumeration Date	:	12/11/2025
Last Update Date	:	12/11/2025

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