Provider Demographics
NPI:1790020063
Name:BULLOCK, RICHARD A (RN)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:A
Last Name:BULLOCK
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7390 N SEYMOUR RD
Mailing Address - Street 2:
Mailing Address - City:OWOSSO
Mailing Address - State:MI
Mailing Address - Zip Code:48867-8611
Mailing Address - Country:US
Mailing Address - Phone:517-256-8522
Mailing Address - Fax:
Practice Address - Street 1:7390 N SEYMOUR RD
Practice Address - Street 2:
Practice Address - City:OWOSSO
Practice Address - State:MI
Practice Address - Zip Code:48867-8611
Practice Address - Country:US
Practice Address - Phone:517-256-8522
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-27
Last Update Date:2012-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704288063163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse