Most Relevant Information
Provider Data
| NPI Number: | 1003572082 |
| Provider Name: | KEVIN JAMES BULLOCK PTA |
| Entity Type: | Individual |
| Taxonomy Code: | 225200000X |
| Specialty: | Physical Therapy Assistant |
| License Number: |
Most Important Dates
| Enumeration Date: | 11/13/2021 |
| Last Updated: | 11/13/2021 |
Provider Practice Location
801 BRIM ST
DESLOGE
MO
636013441
Practice Location Phone/Fax
| Phone: | 5734310223 |
| Fax: |
Provider Mailing Location
801 BRIM ST
DESLOGE
MO
636013441
Provider Mailing Phone/Fax
| Phone: | 5734310223 |
| Fax: |