Healthcare Provider Details

I. General information

NPI: 1881147114
Provider Name (Legal Business Name): RACHEL BUCKNER DERIAN PT, DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: RACHEL LYNN BUCKNER PT, DPT

II. Dates (important events)

Enumeration Date: 08/03/2016
Last Update Date: 08/06/2021
Certification Date: 08/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11605 WASHINGTON PL
LOS ANGELES CA
90066-5013
US

IV. Provider business mailing address

2624 MARTHA AVE
TORRANCE CA
90501-4740
US

V. Phone/Fax

Practice location:
  • Phone: 310-337-7115
  • Fax:
Mailing address:
  • Phone: 540-539-3639
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number291783
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: