1043529167 NPI number — KIM TUCKER APN

Table of content: KIM TUCKER APN (NPI 1043529167)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043529167 NPI number — KIM TUCKER APN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TUCKER
Provider First Name:
KIM
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
APN
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1043529167
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/04/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
101 E MILLER RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
STERLING
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
61081-1252
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
815-625-4790
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
161 N MILL ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TEHACHAPI
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
93561-1347
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
866-707-6664
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/07/2010

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363L00000X , with the licence number:  209008383 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LF0000X , with the licence number: 95006257 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 209008383 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".




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