=====================================================
General NPI Number Information
=====================================================
NPI Number | 1780503300
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TRESURE RUCKER
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/15/2026
-----------------------------------------------------
Last Update Date | 07/15/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8432 MAGNOLIA AVE
-----------------------------------------------------
City | RIVERSIDE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92504-3206
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 951-642-7352
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6039 BOSWELL CT
-----------------------------------------------------
City | RIVERSIDE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92507-8416
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 951-642-7352
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2255A2300X
-----------------------------------------------------
Taxonomy Name | Athletic Trainer
-----------------------------------------------------
License Number | 2000056259
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------