Provider Demographics
NPI:1932860145
Name:BULLOCK, DESIREE
Entity Type:Individual
Prefix:
First Name:DESIREE
Middle Name:
Last Name:BULLOCK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1223 QUARTERHORSE DR
Mailing Address - Street 2:
Mailing Address - City:ALVIN
Mailing Address - State:TX
Mailing Address - Zip Code:77511-1784
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1223 QUARTERHORSE DR
Practice Address - Street 2:
Practice Address - City:ALVIN
Practice Address - State:TX
Practice Address - Zip Code:77511-1784
Practice Address - Country:US
Practice Address - Phone:513-388-1500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-10
Last Update Date:2022-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH3121302Medicaid