MEDICARE: BUCK JACK LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	225100000X	Physical Therapist
2	235Z00000X	Speech-Language Pathologist
3	225X00000X	Occupational Therapist

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1083212393
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BUCK JACK LLC

Provider Business Mailing Address
First Line	:	2233 ACADEMY PL STE 200
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80909-1666
Country	:	US
Telephone Number	:	719-597-0822
Fax Number	:	719-599-4606

Provider Business Practice Location Address
First Line	:	MOUNTAIN VIEW CORE KNOWLEDGE SCHOOL 890 FIELD AVE
Second Line	:
City	:	CANNON CITY
State	:	CO
Zip	:	81212
Country	:	US
Telephone Number	:	719-597-0822
Fax Number	:	719-599-4606

Authorized Official
Title or Position	:	CREDENTIALING SPECIALIST
Name	:	TANNER DENN
Credential	:
Telephone Number	:	719-428-1840

Provider Enumeration Date	:	10/09/2020
Last Update Date	:	02/28/2024

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Directions to “BUCK JACK LLC ” Practice Location

Language	Start Address	Practice Location

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