Healthcare Provider Details

I. General information

NPI: 1821178989
Provider Name (Legal Business Name): LORI BULLOCK RPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/16/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

106 N CRITTENDEN ST
MARSHFIELD MO
65706-1408
US

IV. Provider business mailing address

1911 S NATIONAL AVE SUITE 302
SPRINGFIELD MO
65804-2219
US

V. Phone/Fax

Practice location:
  • Phone: 417-859-3991
  • Fax: 417-859-0100
Mailing address:
  • Phone: 417-881-4164
  • Fax: 417-881-1727

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number109731
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: