Healthcare Provider Details

I. General information

NPI: 1396051777
Provider Name (Legal Business Name): BIJU LUCKOSE RRT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/24/2010
Last Update Date: 08/24/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4576 EMERALD VIS APT K2007
LAKE WORTH FL
33461-5213
US

IV. Provider business mailing address

4576 EMERALD VIS APT K2007
LAKE WORTH FL
33461-5213
US

V. Phone/Fax

Practice location:
  • Phone: 561-891-2255
  • Fax: 561-641-8317
Mailing address:
  • Phone: 561-891-2255
  • Fax: 561-641-8317

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code227900000X
TaxonomyRegistered Respiratory Therapist
License NumberRT10678
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: