Healthcare Provider Details

I. General information

NPI: 1639111594
Provider Name (Legal Business Name): KEVIN B BULLARD MPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2006
Last Update Date: 12/28/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

107 LIVE OAK ST STE C
TABOR CITY NC
28463-2043
US

IV. Provider business mailing address

PO BOX 219
TABOR CITY NC
28463-0219
US

V. Phone/Fax

Practice location:
  • Phone: 252-752-0998
  • Fax:
Mailing address:
  • Phone: 910-377-3146
  • Fax: 910-377-3277

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number10244
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: