MEDICARE: BUCK JACK LLC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	225100000X	Physical Therapist
2	235Z00000X	Speech-Language Pathologist
3	225X00000X	Occupational Therapist

General Provider Information

NPI Number	:	1508472317
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BUCK JACK LLC

Provider Business Mailing Address
First Line	:	685 CITADEL DR E STE 580
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80909-5381
Country	:	US
Telephone Number	:	719-597-0822
Fax Number	:	719-599-4606

Provider Business Practice Location Address
First Line	:	MOUNTAIN VIEW CORE KNOWLEDGE SCHOOL
Second Line	:	890 FIELD AVE
City	:	CANNON CITY
State	:	CO
Zip	:	81212-9250
Country	:	US
Telephone Number	:	719-597-0822
Fax Number	:	719-599-4606

Authorized Official
Title or Position	:	BILLING MANAGER
Name	:	REBECCA NEWMAN
Credential	:
Telephone Number	:	719-597-0822

Provider Enumeration Date	:	09/17/2020
Last Update Date	:	10/01/2020

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Directions to “BUCK JACK LLC ” Practice Location

Language	Start Address	Practice Location

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