Provider Demographics
NPI:1881884641
Name:BUCKLAND EAR NOSE & THROAT LLC
Entity type:Organization
Organization Name:BUCKLAND EAR NOSE & THROAT LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:BETSY
Authorized Official - Middle Name:
Authorized Official - Last Name:GRAVES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:860-645-6675
Mailing Address - Street 1:360 TOLLAND TPKE
Mailing Address - Street 2:SUITE 1E
Mailing Address - City:MANCHESTER
Mailing Address - State:CT
Mailing Address - Zip Code:06042-1771
Mailing Address - Country:US
Mailing Address - Phone:860-645-6675
Mailing Address - Fax:860-645-8677
Practice Address - Street 1:360 TOLLAND TPKE
Practice Address - Street 2:SUITER 1E
Practice Address - City:MANCHESTER
Practice Address - State:CT
Practice Address - Zip Code:06042-1771
Practice Address - Country:US
Practice Address - Phone:860-645-6675
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-27
Last Update Date:2015-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000196235500000X
332B00000X
CT021430174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
No235500000XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistGroup - Multi-Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTC01504Medicare PIN