Healthcare Provider Details

I. General information

NPI: 1700248283
Provider Name (Legal Business Name): REBECCA TUCKER ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/24/2016
Last Update Date: 03/09/2026
Certification Date: 03/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

411 MERCANTILE PLACE SUITE 101
FORT MILL SC
29715
US

IV. Provider business mailing address

411 MERCANTILE PLACE SUITE 101
FORT MILL SC
29715
US

V. Phone/Fax

Practice location:
  • Phone: 704-741-4946
  • Fax:
Mailing address:
  • Phone: 704-741-4946
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number926
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: