Healthcare Provider Details

I. General information

NPI: 1407710692
Provider Name (Legal Business Name): THE LUCK GROUP OUTDOORS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/11/2025
Last Update Date: 12/11/2025
Certification Date: 12/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15265 PROVIDENCE RD
SOUTH PRINCE GEORGE VA
23805-8140
US

IV. Provider business mailing address

PO BOX 1505
PETERSBURG VA
23805-0505
US

V. Phone/Fax

Practice location:
  • Phone: 757-848-7969
  • Fax:
Mailing address:
  • Phone: 757-848-7969
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License Number
License Number State

VIII. Authorized Official

Name: ALTHEIA TYLER
Title or Position: PROGRAM COORDINATOR/OWNER
Credential:
Phone: 757-848-7969