=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104848001
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TUCKER CHIROPRACTIC CENTER PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/23/2006
-----------------------------------------------------
Last Update Date | 06/05/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1179 S GENTRY BLVD
-----------------------------------------------------
City | GENTRY
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72734-9624
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 479-736-8900
-----------------------------------------------------
Fax | 479-736-5133
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 936
-----------------------------------------------------
City | GENTRY
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72734-0936
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 479-736-8900
-----------------------------------------------------
Fax | 479-736-5133
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. JEFFREY A TUCKER
-----------------------------------------------------
Credential | D. C.
-----------------------------------------------------
Telephone | 479-736-8900
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------