Healthcare Provider Details

I. General information

NPI: 1760298681
Provider Name (Legal Business Name): MEGAN JANE BULLOCH LAC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/05/2024
Last Update Date: 05/21/2026
Certification Date: 05/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

705 N LEROUX ST
FLAGSTAFF AZ
86001-3225
US

IV. Provider business mailing address

1843 E SAGEBRUSH RD
WILLIAMS AZ
86046-9342
US

V. Phone/Fax

Practice location:
  • Phone: 928-316-6187
  • Fax:
Mailing address:
  • Phone: 775-790-7606
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberLAC-012319
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: