Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225XP0019X | Occupational Therapist - Physical Rehabilitation | 056.013426 | IL |
NPI | 1124627906 |
---|---|
Provider Name | Mr. Lance Jay Bucher |
First Address | Peoria, IL 61615-1151 |
Second Address | Peoria, IL 61615 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 22/10/2020 |
Last Update Date | 22/10/2020 |