Healthcare Provider Details

I. General information

NPI: 1043275175
Provider Name (Legal Business Name): LUC EMMANUEL KANICKY O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/20/2006
Last Update Date: 05/06/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6911 PISTOL RANGE RD SUITE 103B
TAMPA FL
33635-6335
US

IV. Provider business mailing address

6911 PISTOL RANGE RD SUITE 103B
TAMPA FL
33635-6335
US

V. Phone/Fax

Practice location:
  • Phone: 813-925-3393
  • Fax: 813-925-3394
Mailing address:
  • Phone: 813-925-3393
  • Fax: 813-925-3394

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152WL0500X
TaxonomyLow Vision Rehabilitation Optometrist
License NumberOPC 003906
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: