Provider Demographics
NPI:1982973947
Name:PRUITT, TICCO DARRELL SR
Entity type:Individual
Prefix:MR
First Name:TICCO
Middle Name:DARRELL
Last Name:PRUITT
Suffix:SR
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 1:3030 COVINGTON PIKE
Mailing Address - Street 2:SUITE 180
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38128-5048
Mailing Address - Country:US
Mailing Address - Phone:901-870-2670
Mailing Address - Fax:
Practice Address - Street 1:3030 COVINGTON PIKE
Practice Address - Street 2:SUITE 180
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38128-5048
Practice Address - Country:US
Practice Address - Phone:901-870-2670
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-21
Last Update Date:2011-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)