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NPI Code Detail

MEDICARE: BOONE MARTIN TUCKER

MEDICARE: BOONE MARTIN TUCKER
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
1101YA0400XAddiction (Substance Use Disorder) CounselorRT1437960426CA

General Provider Information

NPI Number : 1902521966
Entity Type Code : Individual
Provider Name (Legal Business Name) : BOONE MARTIN TUCKER
Provider Business Mailing Address
First Line : 2180 JOHNSON AVE
Second Line :
City : SAN LUIS OBISPO
State : CA
Zip : 93401-4558
Country : US
Telephone Number : 805-473-7081
Fax Number :
Provider Business Practice Location Address
First Line : 2180 JOHNSON AVE
Second Line :
City : SAN LUIS OBISPO
State : CA
Zip : 93401-4558
Country : US
Telephone Number : 805-473-7081
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 10/11/2022
Last Update Date : 04/10/2026

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Directions to “ BOONE MARTIN TUCKER ” Practice Location

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