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General NPI Number Information
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NPI Number | 1629834791
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Entity Type | Individual
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Provider Name | JUSTIN LUCKETT LMT
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Gender | Male
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Dates
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Enumeration Date | 02/26/2024
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Last Update Date | 02/26/2024
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Provider Practice Location Address
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Address Line | 8379 DOVE PKWY
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City | CANAL WINCHESTER
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State | OH
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Zip | 43110-7762
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Country | US
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Telephone | 614-809-2055
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Fax |
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Provider Business Mailing Address
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Address Line | 8379 DOVE PKWY
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City | CANAL WINCHESTER
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State | OH
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Zip | 43110-7762
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Country | US
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Telephone | 614-809-2055
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225700000X
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Taxonomy Name | Massage Therapist
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License Number | 33.026777
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License Number State | OH
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