Provider Demographics
NPI:1376901017
Name:TUCKER, DOUGLAS ANTHONY SR (MHS CATC IV 155671)
Entity Type:Individual
Prefix:MR
First Name:DOUGLAS
Middle Name:ANTHONY
Last Name:TUCKER
Suffix:SR
Gender:M
Credentials:MHS CATC IV 155671
Other - Prefix:
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Mailing Address - Street 1:1207 E FRUIT ST
Mailing Address - Street 2:
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92701-4206
Mailing Address - Country:US
Mailing Address - Phone:714-953-9373
Mailing Address - Fax:714-953-7573
Practice Address - Street 1:1207 E FRUIT ST
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92701-4206
Practice Address - Country:US
Practice Address - Phone:714-953-9373
Practice Address - Fax:714-953-7573
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-09
Last Update Date:2016-02-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CA300033CN324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility