Healthcare Provider Details

I. General information

NPI: 1548777428
Provider Name (Legal Business Name): EARL BUCKHANAN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/02/2018
Last Update Date: 01/02/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

460 BRIARWOOD DR STE 510
JACKSON MS
39206-3057
US

IV. Provider business mailing address

PO BOX 13509
JACKSON MS
39236-3509
US

V. Phone/Fax

Practice location:
  • Phone: 601-956-4816
  • Fax: 601-956-4817
Mailing address:
  • Phone: 662-401-2752
  • Fax: 601-956-4817

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: