Provider Demographics
NPI:1487770244
Name:TUCKER, RENWICK EDDIE (DC)
Entity type:Individual
Prefix:
First Name:RENWICK
Middle Name:EDDIE
Last Name:TUCKER
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6980 LAGRANGE CIRCLE NORTH
Mailing Address - Street 2:
Mailing Address - City:CORDOVA
Mailing Address - State:TN
Mailing Address - Zip Code:38018
Mailing Address - Country:US
Mailing Address - Phone:901-251-2549
Mailing Address - Fax:
Practice Address - Street 1:3540 SUMMER AVENUE
Practice Address - Street 2:305
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38122-3600
Practice Address - Country:US
Practice Address - Phone:901-644-5416
Practice Address - Fax:901-323-2997
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1943111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN7762785OtherAETNA
TN4100973OtherBCBS
TN3973714Medicare ID - Type Unspecified
TN7762785OtherAETNA