Basic Information
| Provider Information | |||||||||
| NPI: | 1174796650 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LUCKY CARE MEDICAL, PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 13876 QUEENS BLVD FL 1 | ||||||||
| Address2: | |||||||||
| City: | BRIARWOOD | ||||||||
| State: | NY | ||||||||
| PostalCode: | 114352930 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7188506345 | ||||||||
| FaxNumber: | 7185594895 | ||||||||
| Practice Location | |||||||||
| Address1: | 2108 2ND AVE | ||||||||
| Address2: | |||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100293731 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2128768590 | ||||||||
| FaxNumber: | 2123601844 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/07/2008 | ||||||||
| LastUpdateDate: | 06/21/2018 | ||||||||
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| AuthorizedOfficialLastName: | LUCKY | ||||||||
| AuthorizedOfficialFirstName: | CLYDE | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2128768590 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 167799 | NY | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 01029056 | 05 | NY | MEDICAID | BL0719320 | 01 | NY | DEA | OTHER |