Healthcare Provider Details

I. General information

NPI: 1770783193
Provider Name (Legal Business Name): BUCKELEW PROGRAMS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/24/2007
Last Update Date: 07/24/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

914 MISSION AVE 3RD FLOOR
SAN RAFAEL CA
94901-6106
US

IV. Provider business mailing address

1044 45TH ST #B
EMERYVILLE CA
94608-3392
US

V. Phone/Fax

Practice location:
  • Phone: 415-457-6964
  • Fax:
Mailing address:
  • Phone: 510-653-4180
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302F00000X
TaxonomyExclusive Provider Organization
License Number
License Number State

VIII. Authorized Official

Name: MISS CHELA L. FIELDING
Title or Position: HOUSE MANAGER
Credential:
Phone: 510-653-4180