Provider Demographics
NPI:1558503623
Name:LUCKETT, MICHAEL (CA)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:LUCKETT
Suffix:
Gender:M
Credentials:CA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:380 BRADLEY AVE
Mailing Address - Street 2:
Mailing Address - City:DELAVAN
Mailing Address - State:WI
Mailing Address - Zip Code:53115-1924
Mailing Address - Country:US
Mailing Address - Phone:608-756-4444
Mailing Address - Fax:
Practice Address - Street 1:380 BRADLEY AVE
Practice Address - Street 2:
Practice Address - City:DELAVAN
Practice Address - State:WI
Practice Address - Zip Code:53115-1924
Practice Address - Country:US
Practice Address - Phone:608-756-4444
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-03
Last Update Date:2009-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI65-055171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist