Provider Demographics
NPI:1679753768
Name:BULLOCK, LAURA ANNE (LMT)
Entity Type:Individual
Prefix:MS
First Name:LAURA
Middle Name:ANNE
Last Name:BULLOCK
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4053 SHADOW RUN AVE
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88011-9681
Mailing Address - Country:US
Mailing Address - Phone:575-650-6113
Mailing Address - Fax:
Practice Address - Street 1:1705 N VALLEY DR
Practice Address - Street 2:SUITE 2
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88007-5121
Practice Address - Country:US
Practice Address - Phone:575-650-6113
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-06
Last Update Date:2007-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM4715172M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172M00000XOther Service ProvidersMechanotherapist