Healthcare Provider Details

I. General information

NPI: 1245691344
Provider Name (Legal Business Name): MARK GORDON BUCKLEY L.M.T., M.M.P.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/16/2016
Last Update Date: 03/16/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2740 SILVER AVE
SANDY VALLEY NV
89019-8539
US

IV. Provider business mailing address

2740 SILVER AVE
SANDY VALLEY NV
89019-8539
US

V. Phone/Fax

Practice location:
  • Phone: 702-466-2626
  • Fax:
Mailing address:
  • Phone: 702-466-2626
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberNV20151219246
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: