Healthcare Provider Details

I. General information

NPI: 1053560821
Provider Name (Legal Business Name): BRENDA LOU BUCK RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/16/2008
Last Update Date: 12/31/2021
Certification Date: 12/31/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9900 SE SUNNYSIDE RD
CLACKAMAS OR
97015-9777
US

IV. Provider business mailing address

9900 SE SUNNYSIDE RD
CLACKAMAS OR
97015-9777
US

V. Phone/Fax

Practice location:
  • Phone: 503-571-3764
  • Fax: 503-571-8987
Mailing address:
  • Phone: 503-571-3764
  • Fax: 503-571-8987

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number831
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: