Individual
KENNETH R LUCKAY
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
DO
Contact information
Practice address
4515 BRAMBLETON AVE, SUITE B, ROANOKE, VA 24018-3436
(540) 777-6807
(855) 248-9858
Mailing address
4515 BRAMBLETON AVE, SUITE B, ROANOKE, VA 24018-3436
(540) 777-6807
(855) 248-9858
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
0102049893
VA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
005615127
—
VA
01
—
362206700
DEPT OF LABOR
VA
01
—
441414
ANTHEM
VA
Enumeration date
10/17/2005
Last updated
04/11/2014
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