Provider Demographics
NPI:1144422247
Name:F GRANT BUCKLE MD A PROFESSIONAL CORP
Entity Type:Organization
Organization Name:F GRANT BUCKLE MD A PROFESSIONAL CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:FRANK
Authorized Official - Middle Name:GRANT
Authorized Official - Last Name:BUCKLE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:213-977-1246
Mailing Address - Street 1:1245 WILSHIRE BLVD
Mailing Address - Street 2:SUITE 511
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90017-4810
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1245 WILSHIRE BLVD STE 511
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90017-4805
Practice Address - Country:US
Practice Address - Phone:213-977-1246
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-01
Last Update Date:2008-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA24871174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A248711Medicaid
CA00A248711Medicaid
CAA83216Medicare UPIN
CAA24871AMedicare PIN