1588114938 NPI number — SONYA BUKIRK

Table of content: MRS. WENDY MICHELLE GORDON LSA (NPI 1528079068)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1588114938 NPI number — SONYA BUKIRK

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SONYA BUKIRK
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1588114938
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/10/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3507 D AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KEARNEY
Provider Business Mailing Address State Name:
NE
Provider Business Mailing Address Postal Code:
68847-3055
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
308-293-1385
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
124 W 46TH ST
Provider Second Line Business Practice Location Address:
SUITE #204
Provider Business Practice Location Address City Name:
KEARNEY
Provider Business Practice Location Address State Name:
NE
Provider Business Practice Location Address Postal Code:
68847-8348
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
308-293-1385
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/10/2016

Additional Information

Authorized Official

Authorized Official Last Name:
BUSKIRK
Authorized Official First Name:
SONYA
Authorized Official Middle Name:
ANN
Authorized Official Title or Position:
OWNER/THERAPIST
Authorized Official Telephone Number:
308-293-1385

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X , with the licence number:  2808 , registered in the state of NE ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 10025857400 , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".




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