1205008505 NPI number — ROBERTA KAYE LUCKEL

Table of content: ROBERTA KAYE LUCKEL (NPI 1205008505)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205008505 NPI number — ROBERTA KAYE LUCKEL

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LUCKEL
Provider First Name:
ROBERTA
Provider Middle Name:
KAYE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
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:
1205008505
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/04/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3784 COTTAGE RESERVE RD NE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SOLON
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
52333-9225
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
319-331-1532
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
601 HIGHWAY 6 W
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
IOWA CITY
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
52246-2209
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
319-351-1110
Provider Business Practice Location Address Fax Number:
319-383-2625
Provider Enumeration Date:
03/26/2008

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: 104100000X , with the licence number:  02624 , registered in the state of IA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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