Healthcare Provider Details

I. General information

NPI: 1649435876
Provider Name (Legal Business Name): LUCK MEDICAL CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/28/2008
Last Update Date: 07/28/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

137 1ST AVE
LUCK WI
54853
US

IV. Provider business mailing address

PO BOX 356
LUCK WI
54853-0356
US

V. Phone/Fax

Practice location:
  • Phone: 715-472-2177
  • Fax: 715-472-8787
Mailing address:
  • Phone: 715-472-2177
  • Fax: 715-472-8787

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QR0200X
TaxonomyRadiology Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number43060600
License Number StateWI

VIII. Authorized Official

Name: SCOTT EDIN
Title or Position: CFO ADMINISTRATOR FINANCE
Credential: CFO
Phone: 715-268-0301