Healthcare Provider Details

I. General information

NPI: 1306196969
Provider Name (Legal Business Name): KEVIN L. BUCKELS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/11/2012
Last Update Date: 09/11/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2647 S. ST ELIZABETH BLVD
GONZALES LA
70737
US

IV. Provider business mailing address

2647 S. ST ELIZABETH BLVD
GONZALES LA
70737
US

V. Phone/Fax

Practice location:
  • Phone: 225-647-8511
  • Fax: 225-644-5213
Mailing address:
  • Phone: 225-647-8511
  • Fax: 225-644-5213

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code227800000X
TaxonomyCertified Respiratory Therapist
License NumberCRTLT2440
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: