Healthcare Provider Details

I. General information

NPI: 1952811309
Provider Name (Legal Business Name): BENITA L BUCKNER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/11/2017
Last Update Date: 10/11/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3165 MCKELVEY RD
BRIDGETON MO
63044-2550
US

IV. Provider business mailing address

3165 MCKELVEY RD
BRIDGETON MO
63044-2550
US

V. Phone/Fax

Practice location:
  • Phone: 314-206-3900
  • Fax: 314-206-3992
Mailing address:
  • Phone: 314-206-3900
  • Fax: 314-206-3992

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: