1528193570 NPI number — WILLIAM J. LUCK

Table of content: (NPI 1528193570)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1528193570 NPI number — WILLIAM J. LUCK

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WILLIAM J. LUCK
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
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:
1528193570
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/07/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7108 CAMP BOWIE BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORT WORTH
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76116-7121
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
817-738-3191
Provider Business Mailing Address Fax Number:
817-738-7724

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8401 BOULEVARD 26
Provider Second Line Business Practice Location Address:
STE. 14
Provider Business Practice Location Address City Name:
NORTH RICHLAND HILLS
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76180-5800
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
817-427-8002
Provider Business Practice Location Address Fax Number:
817-485-5998
Provider Enumeration Date:
02/22/2007

Additional Information

Authorized Official

Authorized Official Last Name:
LUCK
Authorized Official First Name:
WILLIAM
Authorized Official Middle Name:
J
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
817-427-8002

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  2393 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 2393 . This is a "TEXAS OPTOMETRY LICENSE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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