Healthcare Provider Details

I. General information

NPI: 1316305345
Provider Name (Legal Business Name): VICTORIA ROSE LUKASIK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/04/2016
Last Update Date: 11/05/2020
Certification Date: 11/05/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1225 E BIG BEAVER RD
TROY MI
48083-1905
US

IV. Provider business mailing address

1412 MOULIN AVE
MADISON HEIGHTS MI
48071-4833
US

V. Phone/Fax

Practice location:
  • Phone: 248-524-8801
  • Fax:
Mailing address:
  • Phone: 586-718-8022
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: