Provider Demographics
NPI:1144220013
Name:PUCKETT, TIMOTHY (DC)
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:
Last Name:PUCKETT
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:PO BOX 297
Mailing Address - Street 2:
Mailing Address - City:YORK
Mailing Address - State:SC
Mailing Address - Zip Code:29745-0297
Mailing Address - Country:US
Mailing Address - Phone:803-684-5504
Mailing Address - Fax:803-684-5496
Practice Address - Street 1:809 E LIBERTY ST
Practice Address - Street 2:
Practice Address - City:YORK
Practice Address - State:SC
Practice Address - Zip Code:29745-1661
Practice Address - Country:US
Practice Address - Phone:803-684-5504
Practice Address - Fax:803-684-5496
Is Sole Proprietor?:No
Enumeration Date:2005-07-21
Last Update Date:2012-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1366111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC1386799898OtherMEDICARE GROUP NPI
SCSC1366Medicaid
SC3664Medicare ID - Type Unspecified
SCSC1366Medicaid