Healthcare Provider Details

I. General information

NPI: 1679753768
Provider Name (Legal Business Name): LAURA ANNE BULLOCK LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/06/2007
Last Update Date: 11/06/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1705 N VALLEY DR SUITE 2
LAS CRUCES NM
88007-5121
US

IV. Provider business mailing address

4053 SHADOW RUN AVE
LAS CRUCES NM
88011-9681
US

V. Phone/Fax

Practice location:
  • Phone: 575-650-6113
  • Fax:
Mailing address:
  • Phone: 575-650-6113
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172M00000X
TaxonomyMechanotherapist
License Number4715
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: