MEDICARE: W.J. LUCK CORPORATION

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	152W00000X	Optometrist	2393	TX

General Provider Information

NPI Number	:	1770766172
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	W.J. LUCK CORPORATION

Provider Business Mailing Address
First Line	:	7108 CAMP BOWIE BLVD
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76116-7121
Country	:	US
Telephone Number	:	817-738-3191
Fax Number	:

Provider Business Practice Location Address
First Line	:	8401 BOULEVARD 26 STE 14
Second Line	:
City	:	NORTH RICHLAND HILLS
State	:	TX
Zip	:	76180-5811
Country	:	US
Telephone Number	:	817-427-8002
Fax Number	:	817-485-5998

Authorized Official
Title or Position	:	GENERAL MANAGER
Name	:	MR. MICHAEL JOSEPH ANDREWS
Credential	:
Telephone Number	:	817-427-8002

Provider Enumeration Date	:	12/10/2007
Last Update Date	:	05/07/2010

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