=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063173003
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOANNE CAROL BUCK LMT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/03/2022
-----------------------------------------------------
Last Update Date | 09/20/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2900 PLANK RD
-----------------------------------------------------
City | ALTOONA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 16601-9361
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 814-946-1668
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3115 COUPON GALLITZIN RD
-----------------------------------------------------
City | COUPON
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 16629-8429
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 814-330-8757
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number | MSG013444
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------