Provider Demographics
NPI:1235319690
Name:BUCKNER, BRIAN DARYL (LMT)
Entity Type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:DARYL
Last Name:BUCKNER
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15495 SW SEQUOIA PKWY
Mailing Address - Street 2:STE. #150
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97224-6100
Mailing Address - Country:US
Mailing Address - Phone:503-957-0338
Mailing Address - Fax:503-726-1152
Practice Address - Street 1:15495 SW SEQUOIA PKWY
Practice Address - Street 2:STE. #150
Practice Address - City:TIGARD
Practice Address - State:OR
Practice Address - Zip Code:97224-6100
Practice Address - Country:US
Practice Address - Phone:503-957-0338
Practice Address - Fax:503-726-1152
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-13
Last Update Date:2009-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR10755225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist