Provider Demographics
NPI:1316014194
Name:RUCKER, ELLEN
Entity Type:Individual
Prefix:DR
First Name:ELLEN
Middle Name:
Last Name:RUCKER
Suffix:
Gender:F
Credentials:
Other - Prefix:DR
Other - First Name:ELLEN
Other - Middle Name:
Other - Last Name:RUCKER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 203
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:SC
Mailing Address - Zip Code:29721
Mailing Address - Country:US
Mailing Address - Phone:803-286-7746
Mailing Address - Fax:803-286-7748
Practice Address - Street 1:106 A WOODLAND DRIVE
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:SC
Practice Address - Zip Code:29720
Practice Address - Country:US
Practice Address - Phone:803-286-7746
Practice Address - Fax:803-286-7748
Is Sole Proprietor?:No
Enumeration Date:2006-11-29
Last Update Date:2011-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2792111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCCH2792Medicaid
SCCH2792Medicaid