Provider Demographics
NPI:1376381152
Name:MISSICK, LUTHER JR
Entity type:Individual
Prefix:
First Name:LUTHER
Middle Name:
Last Name:MISSICK
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:221 SPINOSA ST
Mailing Address - Street 2:
Mailing Address - City:REYNOLDSBURG
Mailing Address - State:OH
Mailing Address - Zip Code:43068-7804
Mailing Address - Country:US
Mailing Address - Phone:614-377-5128
Mailing Address - Fax:
Practice Address - Street 1:491 GEORGESVILLE RD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43228-2420
Practice Address - Country:US
Practice Address - Phone:614-618-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-17
Last Update Date:2024-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator