MEDICARE: MS. LAURA ANNE BULLOCK LMT

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	172M00000X	Mechanotherapist	4715	NM

General Provider Information

NPI Number	:	1679753768
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. LAURA ANNE BULLOCK LMT

Provider Business Mailing Address
First Line	:	4053 SHADOW RUN AVE
Second Line	:
City	:	LAS CRUCES
State	:	NM
Zip	:	88011-9681
Country	:	US
Telephone Number	:	575-650-6113
Fax Number	:

Provider Business Practice Location Address
First Line	:	1705 N VALLEY DR
Second Line	:	SUITE 2
City	:	LAS CRUCES
State	:	NM
Zip	:	88007-5121
Country	:	US
Telephone Number	:	575-650-6113
Fax Number	:

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

Provider Enumeration Date	:	11/06/2007
Last Update Date	:	11/06/2007

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