Provider Demographics
NPI:1831115260
Name:BULLOCK, GEORGE EDWARD JR (MS, ATC)
Entity Type:Individual
Prefix:MR
First Name:GEORGE
Middle Name:EDWARD
Last Name:BULLOCK
Suffix:JR
Gender:M
Credentials:MS, ATC
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Mailing Address - Street 1:8938 BRANDON DR
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71118-2327
Mailing Address - Country:US
Mailing Address - Phone:318-464-5254
Mailing Address - Fax:318-741-9032
Practice Address - Street 1:2000 CENTURYTEL CENTER DR
Practice Address - Street 2:
Practice Address - City:BOSSIER CITY
Practice Address - State:LA
Practice Address - Zip Code:71112-4586
Practice Address - Country:US
Practice Address - Phone:318-752-2847
Practice Address - Fax:318-741-9032
Is Sole Proprietor?:No
Enumeration Date:2006-07-15
Last Update Date:2009-03-05
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
LAATH.J003112255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer