Healthcare Provider Details

I. General information

NPI: 1376901017
Provider Name (Legal Business Name): DOUGLAS ANTHONY TUCKER SR. MHS CATC IV 155671
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/09/2016
Last Update Date: 02/09/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1207 E FRUIT ST
SANTA ANA CA
92701-4206
US

IV. Provider business mailing address

1207 E FRUIT ST
SANTA ANA CA
92701-4206
US

V. Phone/Fax

Practice location:
  • Phone: 714-953-9373
  • Fax: 714-953-7573
Mailing address:
  • Phone: 714-953-9373
  • Fax: 714-953-7573

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number300033CN
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: