Provider Demographics
NPI:1063568533
Name:LUCK, ROBBY S (PT)
Entity type:Individual
Prefix:MR
First Name:ROBBY
Middle Name:S
Last Name:LUCK
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:5547 S 4015 W
Mailing Address - Street 2:#7
Mailing Address - City:TAYLORSVILLE
Mailing Address - State:UT
Mailing Address - Zip Code:84118-4429
Mailing Address - Country:US
Mailing Address - Phone:801-967-6055
Mailing Address - Fax:801-967-6934
Practice Address - Street 1:5547 S 4015 W
Practice Address - Street 2:#7
Practice Address - City:TAYLORSVILLE
Practice Address - State:UT
Practice Address - Zip Code:84118-4429
Practice Address - Country:US
Practice Address - Phone:801-967-6055
Practice Address - Fax:801-967-6934
Is Sole Proprietor?:No
Enumeration Date:2007-01-26
Last Update Date:2007-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT63179552401225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT63179552400001OtherREGENCE BLUE CROSS BLUE S
UT1063568533Medicaid