Provider Demographics
NPI:1265662407
Name:CHARLES T. TUCKER DC, PA
Entity Type:Organization
Organization Name:CHARLES T. TUCKER DC, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:TUCKER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:352-378-3787
Mailing Address - Street 1:4041 NW 37TH PL
Mailing Address - Street 2:SUITE A
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32606-6112
Mailing Address - Country:US
Mailing Address - Phone:352-378-3787
Mailing Address - Fax:352-378-4004
Practice Address - Street 1:4041 NW 37TH PL
Practice Address - Street 2:SUITE A
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32606-6112
Practice Address - Country:US
Practice Address - Phone:352-378-3787
Practice Address - Fax:352-378-4004
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-22
Last Update Date:2013-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH 3743111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL050475100Medicaid
FL88718Medicare PIN