Healthcare Provider Details

I. General information

NPI: 1669102448
Provider Name (Legal Business Name): JEREMIAH LUKERS LAT, CSCS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/14/2022
Last Update Date: 06/14/2022
Certification Date: 06/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

176 ROCKY SHOALS TRL
MOUNT AIRY GA
30563-3669
US

IV. Provider business mailing address

176 ROCKY SHOALS TRL
MOUNT AIRY GA
30563-3669
US

V. Phone/Fax

Practice location:
  • Phone: 814-227-8601
  • Fax:
Mailing address:
  • Phone: 814-227-8601
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT002888
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: