Provider Demographics
NPI:1942708649
Name:BULLOCK, MAGDA LIA (RD)
Entity Type:Individual
Prefix:MS
First Name:MAGDA
Middle Name:LIA
Last Name:BULLOCK
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:759 S. MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:VA
Mailing Address - Zip Code:22664
Mailing Address - Country:US
Mailing Address - Phone:540-459-1309
Mailing Address - Fax:540-459-1127
Practice Address - Street 1:759 S. MAIN STREET
Practice Address - Street 2:
Practice Address - City:WOODSTOCK
Practice Address - State:VA
Practice Address - Zip Code:22664
Practice Address - Country:US
Practice Address - Phone:540-459-1309
Practice Address - Fax:540-459-1127
Is Sole Proprietor?:No
Enumeration Date:2018-01-28
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered