Provider Demographics
NPI:1538241542
Name:BULLOCK, DAVID A (PT)
Entity type:Individual
Prefix:MR
First Name:DAVID
Middle Name:A
Last Name:BULLOCK
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:7201 W CLEARWATER AVE
Mailing Address - Street 2:SUITE B101
Mailing Address - City:KENNEWICK
Mailing Address - State:WA
Mailing Address - Zip Code:99336-1694
Mailing Address - Country:US
Mailing Address - Phone:509-544-0265
Mailing Address - Fax:509-987-1614
Practice Address - Street 1:214 ASH ST
Practice Address - Street 2:
Practice Address - City:GRANDVIEW
Practice Address - State:WA
Practice Address - Zip Code:98930-1319
Practice Address - Country:US
Practice Address - Phone:509-882-3111
Practice Address - Fax:509-882-3362
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2011-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT00007653225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7089956Medicaid
WA7089956Medicaid