Provider Demographics
NPI:1972930071
Name:LUCKEY, CEDRIC MICHAEL (OTR/L)
Entity Type:Individual
Prefix:MR
First Name:CEDRIC
Middle Name:MICHAEL
Last Name:LUCKEY
Suffix:
Gender:M
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 BEAVER CREEK DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29223-7756
Mailing Address - Country:US
Mailing Address - Phone:803-419-9626
Mailing Address - Fax:
Practice Address - Street 1:355 RIDGE RUN TRL
Practice Address - Street 2:
Practice Address - City:IRMO
Practice Address - State:SC
Practice Address - Zip Code:29063-8667
Practice Address - Country:US
Practice Address - Phone:803-271-2364
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-10-03
Last Update Date:2013-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1242174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist