Provider Demographics
NPI:1578642914
Name:RUCKER, MICHAEL GENE (LPO)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:GENE
Last Name:RUCKER
Suffix:
Gender:M
Credentials:LPO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:225 143RD AVE SE
Mailing Address - Street 2:
Mailing Address - City:TENINO
Mailing Address - State:WA
Mailing Address - Zip Code:98589-9604
Mailing Address - Country:US
Mailing Address - Phone:360-264-5342
Mailing Address - Fax:
Practice Address - Street 1:548 SUSSEX AVE W
Practice Address - Street 2:
Practice Address - City:TENINO
Practice Address - State:WA
Practice Address - Zip Code:98589-9341
Practice Address - Country:US
Practice Address - Phone:360-264-6553
Practice Address - Fax:360-264-2621
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-05
Last Update Date:2007-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOI00082222Z00000X
WAPS00081224P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetist
No222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA6050SCOtherREGENCE BS ID
WA9047440OtherDSHS ID
WA91-19414989OtherEIN
WA126134OtherLABOR & INDUSTRIES ID
WA1234640001Medicare NSC