Provider Demographics
NPI:1407406002
Name:BULLOCK, BRIAN G G
Entity Type:Individual
Prefix:
First Name:BRIAN G
Middle Name:G
Last Name:BULLOCK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9000 WAUKEGAN RD STE 100
Mailing Address - Street 2:
Mailing Address - City:MORTON GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60053-2128
Mailing Address - Country:US
Mailing Address - Phone:847-779-6050
Mailing Address - Fax:847-929-1167
Practice Address - Street 1:9000 WAUKEGAN RD STE 100
Practice Address - Street 2:
Practice Address - City:MORTON GROVE
Practice Address - State:IL
Practice Address - Zip Code:60053-2128
Practice Address - Country:US
Practice Address - Phone:847-779-6050
Practice Address - Fax:847-929-1167
Is Sole Proprietor?:No
Enumeration Date:2019-09-16
Last Update Date:2019-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL227.003818225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist