Provider Demographics
NPI:1750519518
Name:TUCKER, EMMET CLIVE (LAC)
Entity type:Individual
Prefix:
First Name:EMMET
Middle Name:CLIVE
Last Name:TUCKER
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1111 S OCEAN BLVD APT 419
Mailing Address - Street 2:
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33432-7659
Mailing Address - Country:US
Mailing Address - Phone:808-283-2105
Mailing Address - Fax:
Practice Address - Street 1:1111 S OCEAN BLVD APT 419
Practice Address - Street 2:
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33432-7659
Practice Address - Country:US
Practice Address - Phone:808-283-2105
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-30
Last Update Date:2022-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI883171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist