Healthcare Provider Details

I. General information

NPI: 1780597401
Provider Name (Legal Business Name): TUCKER OLIVER CHAMPEAU PT, DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/24/2026
Last Update Date: 09/24/2026
Certification Date: 09/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

106 HOSPITAL DR STE 2
CHATSWORTH GA
30705-2070
US

IV. Provider business mailing address

5433 EVERGREEN FOREST CT
FLOWERY BRANCH GA
30542-5736
US

V. Phone/Fax

Practice location:
  • Phone: 706-695-3110
  • Fax:
Mailing address:
  • Phone: 978-799-7080
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT018351
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: