Healthcare Provider Details

I. General information

NPI: 1902566466
Provider Name (Legal Business Name): HARRISON MCCARTNEY TUCKER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/26/2021
Last Update Date: 12/26/2021
Certification Date: 12/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6250 EXCELSIOR BLVD STE 103
SAINT LOUIS PARK MN
55416-2735
US

IV. Provider business mailing address

6700 RICHFIELD PKWY APT 326
RICHFIELD MN
55423-7523
US

V. Phone/Fax

Practice location:
  • Phone: 763-614-0363
  • Fax:
Mailing address:
  • Phone: 715-501-8930
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number00055236
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: