=====================================================
General NPI Number Information
=====================================================
NPI Number | 1902586704
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BRENDA GALE TUCKER LMT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/18/2023
-----------------------------------------------------
Last Update Date | 07/18/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3148 SOUTHGATE CIRCLE SOUTHGATE MASSAGE & WELLNESS CENTER
-----------------------------------------------------
City | SARASOTA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34239
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 941-350-9178
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4001 BENEVA RD UNIT 407
-----------------------------------------------------
City | SARASOTA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34233
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 941-350-9178
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 172M00000X
-----------------------------------------------------
Taxonomy Name | Mechanotherapist
-----------------------------------------------------
License Number | MA20927
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------