Provider Demographics
NPI:1588970479
Name:LUCK, BRIANNE MARIE
Entity type:Individual
Prefix:
First Name:BRIANNE
Middle Name:MARIE
Last Name:LUCK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2813 KENBORG HLS
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON CITY
Mailing Address - State:MO
Mailing Address - Zip Code:65109-1002
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2813 KENBORG HLS
Practice Address - Street 2:
Practice Address - City:JEFFERSON CITY
Practice Address - State:MO
Practice Address - Zip Code:65109-1002
Practice Address - Country:US
Practice Address - Phone:573-353-2760
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-30
Last Update Date:2010-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXB1775413146N00000X
156FX1101X, 156FX1202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1202XEye and Vision Services ProvidersTechnician/TechnologistOptometric Technician
No146N00000XEmergency Medical Service ProvidersEmergency Medical Technician, Basic
No156FX1101XEye and Vision Services ProvidersTechnician/TechnologistOphthalmic Assistant