Provider Demographics
NPI:1295091049
Name:JEFFREY TUCKER A CHIROPRACTIC CORP
Entity type:Organization
Organization Name:JEFFREY TUCKER A CHIROPRACTIC CORP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:H
Authorized Official - Last Name:TUCKER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:310-444-9393
Mailing Address - Street 1:11620 WILSHIRE BLVD STE 710
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90025-1781
Mailing Address - Country:US
Mailing Address - Phone:310-444-9393
Mailing Address - Fax:310-473-6787
Practice Address - Street 1:11620 WILSHIRE BLVD STE 710
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90025-1781
Practice Address - Country:US
Practice Address - Phone:310-444-9393
Practice Address - Fax:310-473-6787
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:JEFFREY TUCKER A CHIROPRACTIC CORP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-04-05
Last Update Date:2018-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC15055111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1295091049Medicaid
CADC15055OtherLICENSE