Individual
MR. MICHAEL GENE RUCKER
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
LPO
Contact information
Practice address
548 SUSSEX AVE W, TENINO, WA 98589-9341
(360) 264-6553
(360) 264-2621
Mailing address
225 143RD AVE SE, TENINO, WA 98589-9604
(360) 264-5342
Taxonomy
Speciality
Code
Description
License number
State
222Z00000X
Orthotist
OI00082
WA
224P00000X
Prosthetist
Primary
PS00081
WA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
126134
LABOR & INDUSTRIES ID
WA
01
—
6050SC
REGENCE BS ID
WA
01
—
9047440
DSHS ID
WA
01
—
91-19414989
EIN
WA
Enumeration date
11/05/2006
Last updated
12/17/2007
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