Provider Demographics
NPI:1881863926
Name:JOSEPH C LUTKA JR.
Entity Type:Organization
Organization Name:JOSEPH C LUTKA JR.
Other - Org Name:BURLESON WELLNESS CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/ PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:CHARLES
Authorized Official - Last Name:LUTKA
Authorized Official - Suffix:JR
Authorized Official - Credentials:LVN
Authorized Official - Phone:817-426-9355
Mailing Address - Street 1:113 N SCOTT ST
Mailing Address - Street 2:
Mailing Address - City:BURLESON
Mailing Address - State:TX
Mailing Address - Zip Code:76028-3924
Mailing Address - Country:US
Mailing Address - Phone:817-426-9355
Mailing Address - Fax:817-426-9357
Practice Address - Street 1:113 N SCOTT ST
Practice Address - Street 2:
Practice Address - City:BURLESON
Practice Address - State:TX
Practice Address - Zip Code:76028-3924
Practice Address - Country:US
Practice Address - Phone:817-426-9355
Practice Address - Fax:817-426-9357
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-22
Last Update Date:2008-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXLVN291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1839078Medicaid