Provider Demographics
NPI:1295805497
Name:BUCKLES, MARK RICHARD (DC)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:RICHARD
Last Name:BUCKLES
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 1:7211 US 42
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:KY
Mailing Address - Zip Code:41042-1901
Mailing Address - Country:US
Mailing Address - Phone:859-817-0817
Mailing Address - Fax:859-817-1329
Practice Address - Street 1:7211 US 42
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:KY
Practice Address - Zip Code:41042-1901
Practice Address - Country:US
Practice Address - Phone:859-817-0817
Practice Address - Fax:859-817-1329
Is Sole Proprietor?:No
Enumeration Date:2006-11-08
Last Update Date:2010-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY4937111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2389204Medicaid
4121701Medicare ID - Type Unspecified
U97658Medicare UPIN