Individual
ANTONIO JERMAINE RUCKER
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Contact information
Practice address
40 ROSWELL AVE, LONG BEACH, CA 90803-2952
(562) 711-1147
Mailing address
40 ROSWELL AVE, LONG BEACH, CA 90803-2952
Taxonomy
Speciality
Code
Description
License number
State
171M00000X
Case Manager/Care Coordinator
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
050703
GREAT-WEST HEALTH CARE
CA
Enumeration date
05/03/2007
Last updated
04/26/2026
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