Provider Demographics
NPI:1255996179
Name:RUCKER, GEORGE ANTHONY
Entity type:Individual
Prefix:
First Name:GEORGE
Middle Name:ANTHONY
Last Name:RUCKER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:508 STAPLES ST
Mailing Address - Street 2:
Mailing Address - City:REIDSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27320-3035
Mailing Address - Country:US
Mailing Address - Phone:336-613-0346
Mailing Address - Fax:336-349-9618
Practice Address - Street 1:3008 NC HIGHWAY 150
Practice Address - Street 2:
Practice Address - City:REIDSVILLE
Practice Address - State:NC
Practice Address - Zip Code:27320-8112
Practice Address - Country:US
Practice Address - Phone:336-613-0346
Practice Address - Fax:336-349-9618
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-06
Last Update Date:2019-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility