Provider Demographics
NPI:1578995304
Name:MAT-SU NEUROLOGY, LLC
Entity Type:Organization
Organization Name:MAT-SU NEUROLOGY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:DWIGHT
Authorized Official - Last Name:BUCKLAND
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:734-657-3942
Mailing Address - Street 1:950 E BOGARD RD
Mailing Address - Street 2:SUITE 213
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99654-7184
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:950 E BOGARD RD
Practice Address - Street 2:SUITE 213
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654-7184
Practice Address - Country:US
Practice Address - Phone:734-657-3942
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-03
Last Update Date:2013-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK992389261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service