Provider Demographics
NPI:1093847873
Name:LUCKAY DOC, PLLC
Entity Type:Organization
Organization Name:LUCKAY DOC, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:D.O
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:R
Authorized Official - Last Name:LUCKAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:540-591-9013
Mailing Address - Street 1:48 STONEY BATTERY RD
Mailing Address - Street 2:
Mailing Address - City:TROUTVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24175-5800
Mailing Address - Country:US
Mailing Address - Phone:540-591-9013
Mailing Address - Fax:314-536-8754
Practice Address - Street 1:48 STONEY BATTERY RD
Practice Address - Street 2:
Practice Address - City:TROUTVILLE
Practice Address - State:VA
Practice Address - Zip Code:24175-5800
Practice Address - Country:US
Practice Address - Phone:540-591-9013
Practice Address - Fax:314-536-8754
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-09
Last Update Date:2012-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0102049890207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty