=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790200186
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BUCKNER IN HOME CARE LTD CO
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/07/2017
-----------------------------------------------------
Last Update Date | 06/20/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 504 FOREST CIR APT 528
-----------------------------------------------------
City | WALTERBORO
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29488-2972
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 803-998-6253
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 504 FOREST CIR APT 528
-----------------------------------------------------
City | WALTERBORO
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29488-2972
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CREDENTIALING SPECIALISTS
-----------------------------------------------------
Name | KIMBERLY DAVIS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 912-484-3879
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 376J00000X
-----------------------------------------------------
Taxonomy Name | Homemaker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 372600000X
-----------------------------------------------------
Taxonomy Name | Adult Companion
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------