Provider Demographics
NPI:1164566840
Name:LUCKETT, MARY ANN (DC)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:ANN
Last Name:LUCKETT
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3289 SALEM RD
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:GA
Mailing Address - Zip Code:30016-1863
Mailing Address - Country:US
Mailing Address - Phone:770-760-1396
Mailing Address - Fax:770-760-7904
Practice Address - Street 1:3289 SALEM RD
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:GA
Practice Address - Zip Code:30016-1863
Practice Address - Country:US
Practice Address - Phone:770-760-1396
Practice Address - Fax:770-760-7904
Is Sole Proprietor?:No
Enumeration Date:2007-02-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACHIR006420111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
35ZCHRXMedicare ID - Type Unspecified
GAU79854Medicare UPIN