Healthcare Provider Details

I. General information

NPI: 1558068742
Provider Name (Legal Business Name): BRIAN C LUTHER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/08/2023
Last Update Date: 02/08/2023
Certification Date: 02/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1320 LOUISIANA AVE STE A
SAINT CLOUD FL
34769-4116
US

IV. Provider business mailing address

4724 LAKE TRUDY DR
SAINT CLOUD FL
34769-1668
US

V. Phone/Fax

Practice location:
  • Phone: 407-593-0122
  • Fax:
Mailing address:
  • Phone: 404-744-8644
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: