Provider Demographics
NPI:1871059683
Name:RUCKER, HUBERT LEE JR
Entity type:Individual
Prefix:MR
First Name:HUBERT
Middle Name:LEE
Last Name:RUCKER
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2921 SPLIT MOUNTAIN LN
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92407-5190
Mailing Address - Country:US
Mailing Address - Phone:909-730-7646
Mailing Address - Fax:
Practice Address - Street 1:2921 SPLIT MOUNTAIN LN
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92407-5190
Practice Address - Country:US
Practice Address - Phone:909-730-7646
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-17
Last Update Date:2019-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)