Provider Demographics
NPI:1700888047
Name:BULLOCK, TODD (CPO)
Entity Type:Individual
Prefix:
First Name:TODD
Middle Name:
Last Name:BULLOCK
Suffix:
Gender:M
Credentials:CPO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:138 JOERSCHKE DR
Mailing Address - Street 2:
Mailing Address - City:GRASS VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:95945-5248
Mailing Address - Country:US
Mailing Address - Phone:530-477-1004
Mailing Address - Fax:530-477-0809
Practice Address - Street 1:138 JOERSCHKE DR
Practice Address - Street 2:
Practice Address - City:GRASS VALLEY
Practice Address - State:CA
Practice Address - Zip Code:95945-5248
Practice Address - Country:US
Practice Address - Phone:530-477-1004
Practice Address - Fax:530-477-0809
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-01
Last Update Date:2020-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAXB0025770Medicaid
CA1055120001Medicare NSC