Healthcare Provider Details

I. General information

NPI: 1740805597
Provider Name (Legal Business Name): CHEYENNE ASHLEY-SUSAN BUKSCH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2020
Last Update Date: 06/08/2020
Certification Date: 06/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

124 VASSAL CT
CONWAY SC
29526-1145
US

IV. Provider business mailing address

124 VASSAL CT
CONWAY SC
29526-1145
US

V. Phone/Fax

Practice location:
  • Phone: 406-794-2651
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: