1194183350 NPI number — ASHLEY BUCKLEY

Table of content: ASHLEY BUCKLEY (NPI 1194183350)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194183350 NPI number — ASHLEY BUCKLEY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BUCKLEY
Provider First Name:
ASHLEY
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
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:
1194183350
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/31/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7107 W. 12TH ST., STE 201
Provider Second Line Business Mailing Address:
SUITE 201
Provider Business Mailing Address City Name:
LITTLE ROCK
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72204-6676
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
501-519-1415
Provider Business Mailing Address Fax Number:
501-325-7938

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7107 WEST 12TH STREET
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
LITTLE ROCK
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72204-6676
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
501-519-1415
Provider Business Practice Location Address Fax Number:
501-537-2718
Provider Enumeration Date:
02/03/2016

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 171M00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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