1003858150 NPI number — CAROL R LUCKEY NP

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003858150 NPI number — CAROL R LUCKEY NP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LUCKEY
Provider First Name:
CAROL
Provider Middle Name:
R
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
NP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1003858150
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/12/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
P.O BOX 11567
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JACKSON
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
38308
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
731-661-0086
Provider Business Mailing Address Fax Number:
731-660-9055

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
120 E CHURCH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LEXINGTON
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
38351
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
731-968-0146
Provider Business Practice Location Address Fax Number:
731-968-9398
Provider Enumeration Date:
06/12/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LP2300X , with the licence number:  APN0000005691 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363L00000X , with the licence number: APN5691 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0000000031363 . This is a "MEMPHIS MANAGED CARE (TLC" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 156102 . This is a "UNISON" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 39006861 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4157526 . This is a "BLUE CROSS BLUE SHIELD TN" identifier . This identifiers is of the category "OTHER".
  • Identifier: 3900686 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4083540 . This is a "TN CARE SELECT" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 4083540 . This is a "BLUE CROSS BLUE SHIELD TN" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".




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