Healthcare Provider Details

I. General information

NPI: 1063870293
Provider Name (Legal Business Name): TUCKERVILLE.LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/02/2016
Last Update Date: 03/24/2023
Certification Date: 03/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

35230 E MICHIGAN AVE
WAYNE MI
48184-3698
US

IV. Provider business mailing address

PO BOX 125
BELLEVILLE MI
48112-0125
US

V. Phone/Fax

Practice location:
  • Phone: 313-312-5706
  • Fax:
Mailing address:
  • Phone: 313-303-7423
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251K00000X
TaxonomyPublic Health or Welfare Agency
License NumberE79564
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License NumberE79564
License Number StateMI
# 4
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License NumberE79564
License Number StateMI
# 6
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License NumberE79564
License Number StateMI

VIII. Authorized Official

Name: MRS. FARTIMA TUCKER
Title or Position: CEO/OWNER
Credential: LMSW, IMH-E(II)
Phone: 313-303-7423