Provider Demographics
NPI:1639111594
Name:BULLARD, KEVIN B (MPT)
Entity Type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:B
Last Name:BULLARD
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 219
Mailing Address - Street 2:
Mailing Address - City:TABOR CITY
Mailing Address - State:NC
Mailing Address - Zip Code:28463-0219
Mailing Address - Country:US
Mailing Address - Phone:910-377-3146
Mailing Address - Fax:910-377-3277
Practice Address - Street 1:107 LIVE OAK ST
Practice Address - Street 2:STE C
Practice Address - City:TABOR CITY
Practice Address - State:NC
Practice Address - Zip Code:28463-2043
Practice Address - Country:US
Practice Address - Phone:252-752-0998
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2016-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC10244225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC230158Medicare PIN