Provider Demographics
NPI:1386723237
Name:LUCK, ROGER WAYNE (OPTICIAN)
Entity type:Individual
Prefix:MR
First Name:ROGER
Middle Name:WAYNE
Last Name:LUCK
Suffix:
Gender:M
Credentials:OPTICIAN
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 121
Mailing Address - Street 2:
Mailing Address - City:NORMAN
Mailing Address - State:NC
Mailing Address - Zip Code:28367-0121
Mailing Address - Country:US
Mailing Address - Phone:910-652-5664
Mailing Address - Fax:
Practice Address - Street 1:211 W BROAD AVE
Practice Address - Street 2:
Practice Address - City:ROCKINGHAM
Practice Address - State:NC
Practice Address - Zip Code:28379-3529
Practice Address - Country:US
Practice Address - Phone:910-997-4949
Practice Address - Fax:910-997-4111
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC398156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCY1925OtherSERVICES FOR BLIND
NC1234KOtherBCBS STATE HEALTH PLAN
NC8801757Medicaid
NC1234KOtherBCBS STATE HEALTH PLAN