Provider Demographics
NPI:1073215794
Name:BUCKMON, JOHN L JR (PP, PSS)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:L
Last Name:BUCKMON
Suffix:JR
Gender:M
Credentials:PP, PSS
Other - Prefix:MR
Other - First Name:GARY
Other - Middle Name:
Other - Last Name:LEE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:QP
Mailing Address - Street 1:603 MCKINLEY AVE
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27834-3035
Mailing Address - Country:US
Mailing Address - Phone:347-633-8460
Mailing Address - Fax:
Practice Address - Street 1:1512 N GREENE ST
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27834-1221
Practice Address - Country:US
Practice Address - Phone:252-621-4336
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-17
Last Update Date:2023-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)