Healthcare Provider Details

I. General information

NPI: 1902521966
Provider Name (Legal Business Name): BOONE MARTIN TUCKER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/11/2022
Last Update Date: 04/10/2026
Certification Date: 04/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2180 JOHNSON AVE
SAN LUIS OBISPO CA
93401-4558
US

IV. Provider business mailing address

2180 JOHNSON AVE
SAN LUIS OBISPO CA
93401-4558
US

V. Phone/Fax

Practice location:
  • Phone: 805-473-7081
  • Fax:
Mailing address:
  • Phone: 805-473-7081
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberRT1437960426
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: