Provider Demographics
NPI:1821489576
Name:TACKETT, ELLIS RAY III (ATC LAT)
Entity Type:Individual
Prefix:MR
First Name:ELLIS
Middle Name:RAY
Last Name:TACKETT
Suffix:III
Gender:M
Credentials:ATC LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:680 HAMBLEY BLVD APT 407
Mailing Address - Street 2:
Mailing Address - City:PIKEVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:41501-3804
Mailing Address - Country:US
Mailing Address - Phone:606-213-1620
Mailing Address - Fax:606-218-5353
Practice Address - Street 1:147 SYCAMORE ST
Practice Address - Street 2:
Practice Address - City:PIKEVILLE
Practice Address - State:KY
Practice Address - Zip Code:41501-9118
Practice Address - Country:US
Practice Address - Phone:606-213-1620
Practice Address - Fax:606-218-5353
Is Sole Proprietor?:No
Enumeration Date:2015-02-16
Last Update Date:2015-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYAT1092174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist