Healthcare Provider Details

I. General information

NPI: 1104805332
Provider Name (Legal Business Name): JEREMY RAY BUCKNER DC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/16/2006
Last Update Date: 11/10/2020
Certification Date: 11/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4540 E BASELINE RD STE 105
MESA AZ
85206-4616
US

IV. Provider business mailing address

PO BOX 11180
TEMPE AZ
85284-0020
US

V. Phone/Fax

Practice location:
  • Phone: 480-819-0393
  • Fax: 480-536-9170
Mailing address:
  • Phone: 480-897-3300
  • Fax: 480-897-3312

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number7490
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code111NR0400X
TaxonomyRehabilitation Chiropractor
License Number4180
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: