MEDICARE: ANTONIO JERMAINE RUCKER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	171M00000X	Case Manager/Care Coordinator

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	050703	OTHER	CA	GREAT-WEST HEALTH CARE

General Provider Information

NPI Number	:	1134331200
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANTONIO JERMAINE RUCKER

Provider Business Mailing Address
First Line	:	40 ROSWELL AVE
Second Line	:
City	:	LONG BEACH
State	:	CA
Zip	:	90803-2952
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	40 ROSWELL AVE
Second Line	:
City	:	LONG BEACH
State	:	CA
Zip	:	90803-2952
Country	:	US
Telephone Number	:	562-711-1147
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/03/2007
Last Update Date	:	04/26/2026

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Directions to “ ANTONIO JERMAINE RUCKER ” Practice Location

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