Healthcare Provider Details

I. General information

NPI: 1336687573
Provider Name (Legal Business Name): LUKE BALKUN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/08/2017
Last Update Date: 08/28/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2262 WESTWOOD RD
N FORT MYERS FL
33917-2536
US

IV. Provider business mailing address

1324 SE 24TH AVE
CAPE CORAL FL
33990-1968
US

V. Phone/Fax

Practice location:
  • Phone: 401-212-7015
  • Fax: 407-960-3009
Mailing address:
  • Phone: 401-212-7015
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: