Healthcare Provider Details

I. General information

NPI: 1972862399
Provider Name (Legal Business Name): LUKE DOUGLAS HEUSEL D.P.T.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2012
Last Update Date: 05/04/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1305 DANTIGNAC ST
AUGUSTA GA
30901-2774
US

IV. Provider business mailing address

1305 DANTIGNAC ST
AUGUSTA GA
30901-2774
US

V. Phone/Fax

Practice location:
  • Phone: 706-922-6555
  • Fax: 706-823-3810
Mailing address:
  • Phone: 706-922-6555
  • Fax: 706-823-3810

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: