MEDICARE: SHANE BULLOCK

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	104100000X	Social Worker

General Provider Information

NPI Number	:	1033465950
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHANE BULLOCK

Provider Business Mailing Address
First Line	:	5456 ARCHES DR
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84129-1704
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5456 ARCHES DR
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84129-1704
Country	:	US
Telephone Number	:	801-815-2833
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/29/2012
Last Update Date	:	07/29/2012

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Directions to “ SHANE BULLOCK ” Practice Location

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