Provider Demographics
NPI:1649601329
Name:TUCKER, SAM
Entity Type:Individual
Prefix:
First Name:SAM
Middle Name:
Last Name:TUCKER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10413 LAKE VISTA CIR
Mailing Address - Street 2:
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33498-6772
Mailing Address - Country:US
Mailing Address - Phone:877-341-8367
Mailing Address - Fax:888-212-1537
Practice Address - Street 1:10413 LAKE VISTA CIR
Practice Address - Street 2:
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33498-6772
Practice Address - Country:US
Practice Address - Phone:877-341-8367
Practice Address - Fax:888-212-1537
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-06
Last Update Date:2013-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL6080160256358332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies