Healthcare Provider Details

I. General information

NPI: 1164040804
Provider Name (Legal Business Name): JAREN STEVEN LUKACH CNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/09/2020
Last Update Date: 07/09/2020
Certification Date: 07/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

251 COUNTY ROAD 120
SAINT CLOUD MN
56303-4872
US

IV. Provider business mailing address

247 9 1/2 ST N
SAUK RAPIDS MN
56379-2225
US

V. Phone/Fax

Practice location:
  • Phone: 320-529-4741
  • Fax:
Mailing address:
  • Phone: 320-237-5848
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number7538
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: