Healthcare Provider Details

I. General information

NPI: 1003336355
Provider Name (Legal Business Name): HUNTER BULLOCK MLS(ASCP)
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2017
Last Update Date: 06/27/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 FOOTHILL DR
SALT LAKE CITY UT
84148-0001
US

IV. Provider business mailing address

4200 N SEASONS VIEW DR APT O2122
LEHI UT
84043-6272
US

V. Phone/Fax

Practice location:
  • Phone: 801-582-1565
  • Fax:
Mailing address:
  • Phone: 806-282-6596
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246RM2200X
TaxonomyMedical Laboratory Technician
License Number25627587
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: