Healthcare Provider Details

I. General information

NPI: 1831483569
Provider Name (Legal Business Name): JANET M BULLOCK RD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/28/2011
Last Update Date: 05/28/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

950 MATTHEW DR
WAYNESBORO MS
39367-2567
US

IV. Provider business mailing address

950 MATTHEW DR
WAYNESBORO MS
39367-2567
US

V. Phone/Fax

Practice location:
  • Phone: 601-735-5151
  • Fax: 601-735-7168
Mailing address:
  • Phone: 601-735-5151
  • Fax: 601-735-7168

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberD1269
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: