=====================================================
General NPI Number Information
=====================================================
NPI Number | 1619214517
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LUCA FAMILY CLINIC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/11/2013
-----------------------------------------------------
Last Update Date | 01/25/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2121 FAIRBURN RD SUITE B
-----------------------------------------------------
City | DOUGLASVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30135-1007
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 256-468-5903
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2121 FAIRBURN RD SUITE B
-----------------------------------------------------
City | DOUGLASVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30135-1007
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 256-468-5903
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER
-----------------------------------------------------
Name | MR. CHIKE C ANIUKWU
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 256-468-5903
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Clinic/Center
-----------------------------------------------------
License Number | 054287
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------