Provider Demographics
NPI:1255214052
Name:TUCK, MELBA ELISHA
Entity type:Individual
Prefix:
First Name:MELBA
Middle Name:ELISHA
Last Name:TUCK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22 SAVANNAH CIR
Mailing Address - Street 2:
Mailing Address - City:HAWKINSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31036-7603
Mailing Address - Country:US
Mailing Address - Phone:404-934-7802
Mailing Address - Fax:
Practice Address - Street 1:3401 US HIGHWAY 80 W
Practice Address - Street 2:
Practice Address - City:TUSKEGEE
Practice Address - State:AL
Practice Address - Zip Code:36083
Practice Address - Country:US
Practice Address - Phone:334-847-0003
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-07-29
Last Update Date:2025-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL003401261QA0600X, 385H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385H00000XRespite Care FacilityRespite Care
No261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care