Healthcare Provider Details

I. General information

NPI: 1881884641
Provider Name (Legal Business Name): BUCKLAND EAR NOSE & THROAT LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/27/2007
Last Update Date: 12/29/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

360 TOLLAND TPKE SUITER 1E
MANCHESTER CT
06042-1771
US

IV. Provider business mailing address

360 TOLLAND TPKE SUITE 1E
MANCHESTER CT
06042-1771
US

V. Phone/Fax

Practice location:
  • Phone: 860-645-6675
  • Fax:
Mailing address:
  • Phone: 860-645-6675
  • Fax: 860-645-8677

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number021430
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code235500000X
TaxonomySpeech/Language/Hearing Specialist/Technologist
License Number000196
License Number StateCT
# 3
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: MRS. BETSY GRAVES
Title or Position: OFFICE MANAGER
Credential:
Phone: 860-645-6675