Healthcare Provider Details

I. General information

NPI: 1235897489
Provider Name (Legal Business Name): AVERY BULLOCK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/06/2021
Last Update Date: 12/06/2021
Certification Date: 12/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1949 THOMSON DR
LYNCHBURG VA
24501-1030
US

IV. Provider business mailing address

1949 THOMSON DR
LYNCHBURG VA
24501-1030
US

V. Phone/Fax

Practice location:
  • Phone: 434-610-7087
  • Fax: 434-266-0583
Mailing address:
  • Phone: 434-610-7087
  • Fax: 434-266-0583

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: