Healthcare Provider Details

I. General information

NPI: 1518012020
Provider Name (Legal Business Name): BUCKELEW PROGRAMS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/24/2007
Last Update Date: 11/30/2023
Certification Date: 11/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2235 MERCURY WAY STE 107
SANTA ROSA CA
95407-5472
US

IV. Provider business mailing address

2235 MERCURY WAY STE 107
SANTA ROSA CA
95407-5472
US

V. Phone/Fax

Practice location:
  • Phone: 707-571-5581
  • Fax: 707-571-5531
Mailing address:
  • Phone: 707-571-5581
  • Fax: 707-571-5531

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State

VIII. Authorized Official

Name: MR. CHRIS KUGHN
Title or Position: CHIEF EXECUTIVE OFFICER
Credential: MSW
Phone: 415-720-4197