Basic Information
| Provider Information | |||||||||
| NPI: | 1821543190 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BUCKNELL | ||||||||
| FirstName: | REYNA | ||||||||
| MiddleName: | MENDOZA | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | P.T., D.P.T. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3633 VISTA WAY | ||||||||
| Address2: | STE 101 | ||||||||
| City: | OCEANSIDE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 920564568 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4073761404 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3633 VISTA WAY | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | OCEANSIDE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 920564568 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7607297298 | ||||||||
| FaxNumber: | 7607297206 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/16/2016 | ||||||||
| LastUpdateDate: | 08/29/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT291779 | CA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.