Provider Demographics
NPI:1427042134
Name:BUCKNER PROSTHETIC AND ORTHOTIC LABORATORIES INC.
Entity Type:Organization
Organization Name:BUCKNER PROSTHETIC AND ORTHOTIC LABORATORIES INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:MARTIN
Authorized Official - Middle Name:L
Authorized Official - Last Name:BUCKNER
Authorized Official - Suffix:
Authorized Official - Credentials:CPO
Authorized Official - Phone:601-944-1130
Mailing Address - Street 1:2 OLD RIVER PL
Mailing Address - Street 2:SUITE D
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39202-3435
Mailing Address - Country:US
Mailing Address - Phone:601-944-1130
Mailing Address - Fax:601-355-7476
Practice Address - Street 1:2 OLD RIVER PL
Practice Address - Street 2:SUITE D
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39202-3435
Practice Address - Country:US
Practice Address - Phone:601-944-1130
Practice Address - Fax:601-355-7476
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-08
Last Update Date:2013-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotistGroup - Multi-Specialty
No224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00040395Medicaid
MS0613250001Medicare ID - Type Unspecified