Healthcare Provider Details

I. General information

NPI: 1255214052
Provider Name (Legal Business Name): MELBA ELISHA TUCK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/29/2025
Last Update Date: 07/29/2025
Certification Date: 07/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3401 US HIGHWAY 80 W
TUSKEGEE AL
36083
US

IV. Provider business mailing address

22 SAVANNAH CIR
HAWKINSVILLE GA
31036-7603
US

V. Phone/Fax

Practice location:
  • Phone: 334-847-0003
  • Fax:
Mailing address:
  • Phone: 404-934-7802
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number003401
License Number StateAL
# 2
Primary TaxonomyY
Taxonomy Code385H00000X
TaxonomyRespite Care
License Number003401
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: