MEDICARE: DR. SPENCER KEVIN LUKE O.D.

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	152W00000X	Optometrist	8024988-9934	UT
2	152W00000X	Optometrist	3427ATI	OR

General Provider Information

NPI Number	:	1356638761
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SPENCER KEVIN LUKE O.D.

Provider Business Mailing Address
First Line	:	10709 S WALTON RD
Second Line	:
City	:	LA GRANDE
State	:	OR
Zip	:	97850-8490
Country	:	US
Telephone Number	:	541-962-7753
Fax Number	:

Provider Business Practice Location Address
First Line	:	10709 S WALTON RD
Second Line	:
City	:	LA GRANDE
State	:	OR
Zip	:	97850-8490
Country	:	US
Telephone Number	:	541-962-7753
Fax Number	:

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

Provider Enumeration Date	:	07/06/2011
Last Update Date	:	09/16/2011

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