Provider Demographics
NPI:1619672011
Name:ISME, LUCKNER I
Entity Type:Individual
Prefix:
First Name:LUCKNER
Middle Name:
Last Name:ISME
Suffix:I
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26736 SAVILLE AVE
Mailing Address - Street 2:
Mailing Address - City:BONITA SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:34135-6339
Mailing Address - Country:US
Mailing Address - Phone:239-213-8179
Mailing Address - Fax:
Practice Address - Street 1:26736 SAVILLE AVE
Practice Address - Street 2:
Practice Address - City:BONITA SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:34135-6339
Practice Address - Country:US
Practice Address - Phone:239-213-8179
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-04
Last Update Date:2023-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
172A00000X
FLI250520832670172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver