Healthcare Provider Details

I. General information

NPI: 1427042134
Provider Name (Legal Business Name): BUCKNER PROSTHETIC AND ORTHOTIC LABORATORIES INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/08/2005
Last Update Date: 10/04/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 OLD RIVER PL SUITE D
JACKSON MS
39202-3435
US

IV. Provider business mailing address

2 OLD RIVER PL SUITE D
JACKSON MS
39202-3435
US

V. Phone/Fax

Practice location:
  • Phone: 601-944-1130
  • Fax: 601-355-7476
Mailing address:
  • Phone: 601-944-1130
  • Fax: 601-355-7476

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code224P00000X
TaxonomyProsthetist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code222Z00000X
TaxonomyOrthotist
License Number
License Number State

VIII. Authorized Official

Name: MR. MARTIN L BUCKNER
Title or Position: OWNER
Credential: C.P.O.
Phone: 601-944-1130