Provider Demographics
NPI:1649333048
Name:BULLOCK, VENETTA
Entity type:Individual
Prefix:MS
First Name:VENETTA
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 1:125 DONS WAY
Mailing Address - Street 2:
Mailing Address - City:HOT SPRINGS
Mailing Address - State:AR
Mailing Address - Zip Code:71913
Mailing Address - Country:US
Mailing Address - Phone:501-620-5130
Mailing Address - Fax:501-620-5109
Practice Address - Street 1:201 N 26TH ST
Practice Address - Street 2:
Practice Address - City:ARKADELPHIA
Practice Address - State:AR
Practice Address - Zip Code:71923-4336
Practice Address - Country:US
Practice Address - Phone:870-246-1916
Practice Address - Fax:501-620-5109
Is Sole Proprietor?:No
Enumeration Date:2006-12-18
Last Update Date:2010-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR116399726Medicaid