Healthcare Provider Details

I. General information

NPI: 1144152463
Provider Name (Legal Business Name): KALEB D TUCKER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2026
Last Update Date: 06/01/2026
Certification Date: 06/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PO BOX 3187
AUGUSTA GA
30914-3187
US

IV. Provider business mailing address

2412 LUXEMBOURG DR
AUGUSTA GA
30906-4037
US

V. Phone/Fax

Practice location:
  • Phone: 706-736-2499
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: