Healthcare Provider Details

I. General information

NPI: 1790020063
Provider Name (Legal Business Name): RICHARD A. BULLOCK R.N.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/27/2012
Last Update Date: 11/27/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7390 N SEYMOUR RD
OWOSSO MI
48867-8611
US

IV. Provider business mailing address

7390 N SEYMOUR RD
OWOSSO MI
48867-8611
US

V. Phone/Fax

Practice location:
  • Phone: 517-256-8522
  • Fax:
Mailing address:
  • Phone: 517-256-8522
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number4704288063
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: