Provider Demographics
NPI:1811035397
Name:BUCKLEY, BRENDEN K (DC)
Entity Type:Individual
Prefix:
First Name:BRENDEN
Middle Name:K
Last Name:BUCKLEY
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:539 BALTIMORE ST
Mailing Address - Street 2:
Mailing Address - City:HANOVER
Mailing Address - State:PA
Mailing Address - Zip Code:17331-3315
Mailing Address - Country:US
Mailing Address - Phone:717-633-5411
Mailing Address - Fax:717-633-9825
Practice Address - Street 1:539 BALTIMORE ST
Practice Address - Street 2:
Practice Address - City:HANOVER
Practice Address - State:PA
Practice Address - Zip Code:17331-3315
Practice Address - Country:US
Practice Address - Phone:717-633-5411
Practice Address - Fax:717-633-9825
Is Sole Proprietor?:No
Enumeration Date:2007-02-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC-004120L111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1429343OtherBLUE SHIELD GROUP NUMBER
PA1429343OtherBLUE SHIELD GROUP NUMBER
PABU657583QF6Medicare ID - Type UnspecifiedMEDICARE