Provider Demographics
NPI:1932251899
Name:LUCKOCK, JAMES STEPHEN (DC)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:STEPHEN
Last Name:LUCKOCK
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX #1765
Mailing Address - Street 2:
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83303-1765
Mailing Address - Country:US
Mailing Address - Phone:208-733-0522
Mailing Address - Fax:208-733-0522
Practice Address - Street 1:105 FILER AVENUE
Practice Address - Street 2:
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301
Practice Address - Country:US
Practice Address - Phone:208-733-0522
Practice Address - Fax:208-733-0522
Is Sole Proprietor?:No
Enumeration Date:2007-01-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDCHIA498111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
1671882Medicare ID - Type Unspecified