Provider Demographics
NPI:1285454694
Name:TUCKER, REGGIE
Entity type:Individual
Prefix:
First Name:REGGIE
Middle Name:
Last Name:TUCKER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3120 BERRY FARM RD
Mailing Address - Street 2:
Mailing Address - City:CARLISLE
Mailing Address - State:SC
Mailing Address - Zip Code:29031-9242
Mailing Address - Country:US
Mailing Address - Phone:803-477-2564
Mailing Address - Fax:
Practice Address - Street 1:3120 BERRY FARM RD
Practice Address - Street 2:
Practice Address - City:CARLISLE
Practice Address - State:SC
Practice Address - Zip Code:29031-9242
Practice Address - Country:US
Practice Address - Phone:803-477-2564
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-11
Last Update Date:2024-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC007865475172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver