Provider Demographics
NPI:1649435876
Name:LUCK MEDICAL CLINIC
Entity type:Organization
Organization Name:LUCK MEDICAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO ADMINISTRATOR FINANCE
Authorized Official - Prefix:
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:
Authorized Official - Last Name:EDIN
Authorized Official - Suffix:
Authorized Official - Credentials:CFO
Authorized Official - Phone:715-268-0301
Mailing Address - Street 1:PO BOX 356
Mailing Address - Street 2:
Mailing Address - City:LUCK
Mailing Address - State:WI
Mailing Address - Zip Code:54853-0356
Mailing Address - Country:US
Mailing Address - Phone:715-472-2177
Mailing Address - Fax:715-472-8787
Practice Address - Street 1:137 1ST AVE
Practice Address - Street 2:
Practice Address - City:LUCK
Practice Address - State:WI
Practice Address - Zip Code:54853
Practice Address - Country:US
Practice Address - Phone:715-472-2177
Practice Address - Fax:715-472-8787
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:AMERY REGIONAL MEDICAL CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-07-28
Last Update Date:2008-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QR0200X, 291U00000X
WI43060600261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
No261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
No291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32832000Medicaid