Provider Demographics
NPI:1730366535
Name:TUCKER CHIROPRACTIC CENTER
Entity type:Organization
Organization Name:TUCKER CHIROPRACTIC CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GLENN
Authorized Official - Middle Name:M
Authorized Official - Last Name:TUCKER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:660-684-6161
Mailing Address - Street 1:PO BOX 133
Mailing Address - Street 2:
Mailing Address - City:JAMESPORT
Mailing Address - State:MO
Mailing Address - Zip Code:64648-0133
Mailing Address - Country:US
Mailing Address - Phone:660-684-6161
Mailing Address - Fax:660-684-6334
Practice Address - Street 1:208 SOUTH WILLIAMS STREET
Practice Address - Street 2:
Practice Address - City:JAMESPORT
Practice Address - State:MO
Practice Address - Zip Code:64648-0133
Practice Address - Country:US
Practice Address - Phone:660-684-6161
Practice Address - Fax:660-684-6334
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-24
Last Update Date:2008-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO0003978111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOT43364Medicare UPIN
MOC370000Medicare PIN