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General NPI Number Information
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NPI Number | 1184976409
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Entity Type | Individual
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Provider Name | RYAN DOUGLAS BULLOCK AUD
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Gender | Male
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Dates
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Enumeration Date | 10/10/2012
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Last Update Date | 09/26/2018
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Provider Practice Location Address
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Address Line | 1360 W 6TH ST STE 243
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City | SAN PEDRO
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State | CA
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Zip | 90732-3589
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Country | US
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Telephone | 424-570-0117
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Fax | 424-570-0499
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Provider Business Mailing Address
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Address Line | 600 MONTEREY BLVD APT 10
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City | HERMOSA BEACH
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State | CA
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Zip | 90254-4583
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Country | US
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Telephone | 479-459-2261
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 231H00000X
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Taxonomy Name | Audiologist
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License Number |
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License Number State |
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