Provider Demographics
NPI:1477170777
Name:BUCKHANON, TEQUILA
Entity Type:Individual
Prefix:
First Name:TEQUILA
Middle Name:
Last Name:BUCKHANON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5701 SHINGLE CREEK PKWY STE 250H
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN CENTER
Mailing Address - State:MN
Mailing Address - Zip Code:55430-2344
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5701 SHINGLE CREEK PKWY STE 250H
Practice Address - Street 2:
Practice Address - City:BROOKLYN CENTER
Practice Address - State:MN
Practice Address - Zip Code:55430-2344
Practice Address - Country:US
Practice Address - Phone:612-695-5614
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-02
Last Update Date:2020-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
343900000X
MN10827598251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
No343900000XTransportation ServicesNon-emergency Medical Transport (VAN)