Provider Demographics
NPI:1225472855
Name:RUCKER, DANIEL J
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:J
Last Name:RUCKER
Suffix:
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 1:5230 W PATRICK LANE
Mailing Address - Street 2:SUITE 140
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89015
Mailing Address - Country:US
Mailing Address - Phone:702-504-5213
Mailing Address - Fax:
Practice Address - Street 1:5230 W PATRICK LN
Practice Address - Street 2:SUITE 140
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89118-2851
Practice Address - Country:US
Practice Address - Phone:702-504-5213
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-25
Last Update Date:2013-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV1702142613225400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner