Provider Demographics
NPI:1609891688
Name:TUCKER, TRAVIS WAYNE (D C)
Entity Type:Individual
Prefix:
First Name:TRAVIS
Middle Name:WAYNE
Last Name:TUCKER
Suffix:
Gender:M
Credentials:D C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2472 CHAMBERS RD
Mailing Address - Street 2:STE.100
Mailing Address - City:TUSTIN
Mailing Address - State:CA
Mailing Address - Zip Code:92780-6954
Mailing Address - Country:US
Mailing Address - Phone:949-767-7090
Mailing Address - Fax:
Practice Address - Street 1:2472 CHAMBERS RD
Practice Address - Street 2:STE.100
Practice Address - City:TUSTIN
Practice Address - State:CA
Practice Address - Zip Code:92780-6954
Practice Address - Country:US
Practice Address - Phone:949-767-7090
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-12
Last Update Date:2014-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC16567111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC0165670OtherBLUE SHIELD IDENTIFIER
CAWDC16567AMedicare PIN
CATO6187Medicare UPIN