Healthcare Provider Details

I. General information

NPI: 1710098835
Provider Name (Legal Business Name): CHARLES F LUCKHARDT II M.ED.,C.P.O.,L.P.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 11/16/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1411 NW 23RD AVE
CHIEFLAND FL
32626-1976
US

IV. Provider business mailing address

1411 NW 23RD AVE
CHIEFLAND FL
32626-1976
US

V. Phone/Fax

Practice location:
  • Phone: 352-493-0360
  • Fax: 352-493-0369
Mailing address:
  • Phone: 352-493-0360
  • Fax: 352-493-0369

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code222Z00000X
TaxonomyOrthotist
License NumberPOR92
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code224P00000X
TaxonomyProsthetist
License NumberPOR92
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: