Doctor Name: | MR. ELLIS RAY TACKETT |
NPI Number: | 1821489576 |
Entity Type Code: | Individual (1) |
Gender: | M |
Credentials: | ATC LAT |
License Number: | AT1092 |
Business Practice Address: | 147 Sycamore St Pikeville, KY - 415019118 |
Business Phone Number: | 6062131620 |
Business Fax Number: | 6062185353 |
Mailing Address: | 680 Hambley Blvd Apt 407, PIKEVILLE |
State: | KY |
Postal Code: | 415013804 |
Phone Number: | 6062131620 |
Fax Number: | 6062185353 |
NPI Enumeration Date: | 02/16/2015 |
NPI Last Update Date: | 02/16/2015 |
Replacement NPI: | 0 |
NPI Deactivation Date: | |
NPI Reactivation Date: |
Taxonomy Information: | |
Healthcare Provider Taxonomy: | 174400000X |
License Number: | AT1092 |
Healthcare Provider Taxonomy: (Secondary) | Y |
State: | KY |
Taxonomy Type: | Other Service Providers |
Taxonomy Classification: | Specialist |
Taxonomy Specialization: | |
Taxonomy Definition: | An individual educated and trained in an applied knowledge discipline used in the performance of work at a level requiring knowledge and skills beyond or apart from that provided by a general education or liberal arts degree. |