=====================================================
General NPI Number Information
=====================================================
NPI Number | 1568187862
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DAVID CHRISTOPHER BUCKNER LMT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/10/2022
-----------------------------------------------------
Last Update Date | 10/10/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 111 HOMANS AVE
-----------------------------------------------------
City | CLOSTER
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07624-2728
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 201-784-5575
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 167 HUNGRY HOLLOW RD
-----------------------------------------------------
City | CHESTNUT RIDGE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10977-6155
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 845-248-9032
-----------------------------------------------------
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 | 18KT01360000
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------