Basic Information
| Provider Information | |||||||||
| NPI: | 1104805332 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BUCKNER | ||||||||
| FirstName: | JEREMY | ||||||||
| MiddleName: | RAY | ||||||||
| NamePrefix: | |||||||||
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| Credential: | DC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 11180 | ||||||||
| Address2: | |||||||||
| City: | TEMPE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852840020 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4808973300 | ||||||||
| FaxNumber: | 4808973312 | ||||||||
| Practice Location | |||||||||
| Address1: | 4540 E BASELINE RD STE 105 | ||||||||
| Address2: | |||||||||
| City: | MESA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852064616 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4808190393 | ||||||||
| FaxNumber: | 4805369170 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/16/2006 | ||||||||
| LastUpdateDate: | 11/10/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/10/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 111NR0400X | 4180 | AZ | N | Chiropractic Providers | Chiropractor | Rehabilitation | 111N00000X | 7490 | AZ | Y | Chiropractic Providers | Chiropractor |
No ID Information.