Provider Demographics
NPI:1174753354
Name:BULLOCH, JAY (LAC)
Entity type:Individual
Prefix:MR
First Name:JAY
Middle Name:
Last Name:BULLOCH
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4132 MADISON AVE
Mailing Address - Street 2:
Mailing Address - City:CULVER CITY
Mailing Address - State:CA
Mailing Address - Zip Code:90232-3222
Mailing Address - Country:US
Mailing Address - Phone:310-428-4841
Mailing Address - Fax:
Practice Address - Street 1:4132 MADISON AVE
Practice Address - Street 2:
Practice Address - City:CULVER CITY
Practice Address - State:CA
Practice Address - Zip Code:90232-3222
Practice Address - Country:US
Practice Address - Phone:310-428-4841
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-22
Last Update Date:2009-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC 11576171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist