Basic Information
| Provider Information | |||||||||
| NPI: | 1376182162 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BUCKEYE M, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2121 MESA DR | ||||||||
| Address2: | |||||||||
| City: | BOULDER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 803043621 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3034424037 | ||||||||
| FaxNumber: | 3034422348 | ||||||||
| Practice Location | |||||||||
| Address1: | 2121 MESA DR | ||||||||
| Address2: | |||||||||
| City: | BOULDER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 803043621 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3034424037 | ||||||||
| FaxNumber: | 3034422348 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/27/2019 | ||||||||
| LastUpdateDate: | 12/27/2019 | ||||||||
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| AuthorizedOfficialLastName: | KORETKE | ||||||||
| AuthorizedOfficialFirstName: | MARY | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR OF REIMBURSEMENT | ||||||||
| AuthorizedOfficialTelephone: | 3032383838 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 12/27/2019 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
No ID Information.