Healthcare Provider Details

I. General information

NPI: 1043853278
Provider Name (Legal Business Name): CHARLES MAHLON TUCKER PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/21/2019
Last Update Date: 11/27/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

112 W CITRUS ST
ALTAMONTE SPRINGS FL
32714-2502
US

IV. Provider business mailing address

623 N HYER AVE
ORLANDO FL
32803-4629
US

V. Phone/Fax

Practice location:
  • Phone: 407-865-5642
  • Fax:
Mailing address:
  • Phone: 786-368-4791
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA29584
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: