Provider Demographics
NPI:1457448938
Name:BULLOCK, TIMOTHY (DC)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:
Last Name:BULLOCK
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15550 ROCKFIELD BLVD
Mailing Address - Street 2:B220
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92618-2720
Mailing Address - Country:US
Mailing Address - Phone:949-598-9999
Mailing Address - Fax:949-598-9990
Practice Address - Street 1:1712 OCEAN PARK BLVD
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90405-4902
Practice Address - Country:US
Practice Address - Phone:310-394-1515
Practice Address - Fax:310-392-7676
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-06
Last Update Date:2010-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC13957111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC0139570OtherBLUE SHIELD
CAT17658Medicare UPIN
CADC13957Medicare ID - Type Unspecified