MEDICARE: MRS. DEDE LUCZAK OWNER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	247200000X	Other Technician	CGC062824	FL

General Provider Information

NPI Number	:	1225419260
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. DEDE LUCZAK OWNER

Provider Business Mailing Address
First Line	:	2600 SENECA DR
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32259-2117
Country	:	US
Telephone Number	:	904-449-1496
Fax Number	:	904-436-5977

Provider Business Practice Location Address
First Line	:	2600 SENECA DR
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32259-2117
Country	:	US
Telephone Number	:	904-449-1496
Fax Number	:	904-436-5977

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/16/2015
Last Update Date	:	06/16/2015

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