Provider Demographics
NPI:1245691344
Name:BUCKLEY, MARK GORDON (LMT, MMP)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:GORDON
Last Name:BUCKLEY
Suffix:
Gender:M
Credentials:LMT, MMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2740 SILVER AVE
Mailing Address - Street 2:
Mailing Address - City:SANDY VALLEY
Mailing Address - State:NV
Mailing Address - Zip Code:89019-8539
Mailing Address - Country:US
Mailing Address - Phone:702-466-2626
Mailing Address - Fax:
Practice Address - Street 1:2740 SILVER AVE
Practice Address - Street 2:
Practice Address - City:SANDY VALLEY
Practice Address - State:NV
Practice Address - Zip Code:89019-8539
Practice Address - Country:US
Practice Address - Phone:702-466-2626
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-16
Last Update Date:2016-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVNV20151219246225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist