Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111N00000X | Chiropractor | 7490 | AZ |
N | 111NR0400X | Rehabilitation Chiropractor | 4180 | AZ |
NPI | 1104805332 |
---|---|
Provider Name | Jeremy Ray Buckner |
First Address | Tempe, AZ 85284-0020 |
Second Address | Mesa, AZ 85206-4616 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 16/01/2006 |
Last Update Date | 10/11/2020 |