Provider Demographics
NPI:1184976409
Name:BULLOCK, RYAN DOUGLAS (AUD)
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:DOUGLAS
Last Name:BULLOCK
Suffix:
Gender:M
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 MONTEREY BLVD APT 10
Mailing Address - Street 2:
Mailing Address - City:HERMOSA BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90254-4583
Mailing Address - Country:US
Mailing Address - Phone:479-459-2261
Mailing Address - Fax:
Practice Address - Street 1:1360 W 6TH ST STE 243
Practice Address - Street 2:
Practice Address - City:SAN PEDRO
Practice Address - State:CA
Practice Address - Zip Code:90732-3589
Practice Address - Country:US
Practice Address - Phone:424-570-0117
Practice Address - Fax:424-570-0499
Is Sole Proprietor?:No
Enumeration Date:2012-10-10
Last Update Date:2018-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist