MEDICARE: KRYSTLE 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	1744P3200X	Prosthetics Case Management	34984	SC

General Provider Information

NPI Number	:	1831829902
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KRYSTLE BUCKNER

Provider Business Mailing Address
First Line	:	1930 OAK ST
Second Line	:
City	:	COLUMBIA
State	:	SC
Zip	:	29204-1025
Country	:	US
Telephone Number	:	803-463-1023
Fax Number	:

Provider Business Practice Location Address
First Line	:	1930 OAK ST
Second Line	:
City	:	COLUMBIA
State	:	SC
Zip	:	29204-1025
Country	:	US
Telephone Number	:	803-463-1023
Fax Number	:

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

Provider Enumeration Date	:	06/13/2022
Last Update Date	:	06/13/2022

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Directions to “ KRYSTLE BUCKNER ” Practice Location

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