Provider Demographics
NPI:1538578265
Name:RUCKER, IVORI
Entity type:Individual
Prefix:
First Name:IVORI
Middle Name:
Last Name:RUCKER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6775 REDMAN ST
Mailing Address - Street 2:
Mailing Address - City:WESTLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48185-2740
Mailing Address - Country:US
Mailing Address - Phone:734-596-8311
Mailing Address - Fax:
Practice Address - Street 1:43700 WOODWARD AVE
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD HILLS
Practice Address - State:MI
Practice Address - Zip Code:48302-5058
Practice Address - Country:US
Practice Address - Phone:734-596-8311
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-06
Last Update Date:2025-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7501003769225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist