Individual
MR. ELLIS RAY TACKETT III
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
ATC LAT
Contact information
Practice address
147 SYCAMORE ST, PIKEVILLE, KY 41501-9118
(606) 213-1620
(606) 218-5353
Mailing address
680 HAMBLEY BLVD APT 407, PIKEVILLE, KY 41501-3804
(606) 213-1620
(606) 218-5353
Taxonomy
Speciality
Code
Description
License number
State
174400000X
Specialist
Primary
AT1092
KY
Other
Enumeration date
02/16/2015
Last updated
02/16/2015
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