Provider Demographics
NPI:1083667463
Name:TUCKER, CASEY L (DC)
Entity Type:Individual
Prefix:
First Name:CASEY
Middle Name:L
Last Name:TUCKER
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1211 COLLEGE AVE
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95404-3907
Mailing Address - Country:US
Mailing Address - Phone:707-526-9355
Mailing Address - Fax:707-526-9081
Practice Address - Street 1:1211 COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95404-3907
Practice Address - Country:US
Practice Address - Phone:707-526-9355
Practice Address - Fax:707-526-9081
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-18
Last Update Date:2012-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC 23602111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC 23602OtherLICENSE NUMBER
CADC0236020Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER
U54854Medicare UPIN