Provider Demographics
NPI:1952433013
Name:TUCKER, GLENN M (DC)
Entity Type:Individual
Prefix:DR
First Name:GLENN
Middle Name:M
Last Name:TUCKER
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 133
Mailing Address - Street 2:
Mailing Address - City:JAMESPORT
Mailing Address - State:MO
Mailing Address - Zip Code:64648-0133
Mailing Address - Country:US
Mailing Address - Phone:660-684-6161
Mailing Address - Fax:660-684-6334
Practice Address - Street 1:208 SOUTH WILLIAMS STREET
Practice Address - Street 2:
Practice Address - City:JAMESPORT
Practice Address - State:MO
Practice Address - Zip Code:64648-0133
Practice Address - Country:US
Practice Address - Phone:660-684-6161
Practice Address - Fax:660-684-6334
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-12
Last Update Date:2011-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO003978111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO11690032OtherCAQH
T43364Medicare UPIN
MO000F758Medicare PIN