MEDICARE: BROCK BUCKNER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225X00000X	Occupational Therapist	4915	SC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	4915	OTHER	SC	SC OT LC

General Provider Information

NPI Number	:	1013417229
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BROCK BUCKNER

Provider Business Mailing Address
First Line	:	159 OAK CREEK LANE
Second Line	:
City	:	PILOT
State	:	VA
Zip	:	24138
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	159 OAK CREEK LANE
Second Line	:
City	:	PILOT
State	:	VA
Zip	:	24138
Country	:	US
Telephone Number	:	540-320-9260
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/14/2018
Last Update Date	:	02/14/2018

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Directions to “ BROCK BUCKNER ” Practice Location

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