Provider Demographics
NPI:1508316159
Name:BULLOCK, RIANN (MSTOM, LAC)
Entity Type:Individual
Prefix:
First Name:RIANN
Middle Name:
Last Name:BULLOCK
Suffix:
Gender:F
Credentials:MSTOM, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4319 RIALTO ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92107-1123
Mailing Address - Country:US
Mailing Address - Phone:919-247-5960
Mailing Address - Fax:
Practice Address - Street 1:4319 RIALTO ST
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92107-1123
Practice Address - Country:US
Practice Address - Phone:919-247-5960
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-06
Last Update Date:2016-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA17280171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist