Healthcare Provider Details

I. General information

NPI: 1205121092
Provider Name (Legal Business Name): RENEE L. BULLARD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2011
Last Update Date: 09/02/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5841 HWY. 421 S.
BUIES CREEK NC
27506-0457
US

IV. Provider business mailing address

284 EXECUTIVE PARK DR SUITE 100
CONCORD NC
28025-1831
US

V. Phone/Fax

Practice location:
  • Phone: 910-893-5727
  • Fax:
Mailing address:
  • Phone: 704-939-1118
  • Fax: 704-939-1173

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: