Healthcare Provider Details

I. General information

NPI: 1831849470
Provider Name (Legal Business Name): AVERY ALEXANDER BUCKLES
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/26/2022
Last Update Date: 10/06/2025
Certification Date: 10/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

910 WALLACE AVE STE 102
LEITCHFIELD KY
42754
US

IV. Provider business mailing address

PO BOX 23229
OWENSBORO KY
42304-3229
US

V. Phone/Fax

Practice location:
  • Phone: 270-259-8888
  • Fax:
Mailing address:
  • Phone: 270-691-8070
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number06099
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: