Healthcare Provider Details

I. General information

NPI: 1235319690
Provider Name (Legal Business Name): BRIAN DARYL BUCKNER L.M.T.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/13/2007
Last Update Date: 08/04/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15495 SW SEQUOIA PKWY STE. #150
TIGARD OR
97224-6100
US

IV. Provider business mailing address

15495 SW SEQUOIA PKWY STE. #150
TIGARD OR
97224-6100
US

V. Phone/Fax

Practice location:
  • Phone: 503-957-0338
  • Fax: 503-726-1152
Mailing address:
  • Phone: 503-957-0338
  • Fax: 503-726-1152

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number10755
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: