Basic Information
| Provider Information | |||||||||
| NPI: | 1871185470 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BULLOCK | ||||||||
| FirstName: | ZACHARY | ||||||||
| MiddleName: | |||||||||
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| NameSuffix: | |||||||||
| Credential: | RBT | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1701 LIBRARY BLVD STE A | ||||||||
| Address2: | |||||||||
| City: | GREENWOOD | ||||||||
| State: | IN | ||||||||
| PostalCode: | 461421567 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3178819923 | ||||||||
| FaxNumber: | 3178819966 | ||||||||
| Practice Location | |||||||||
| Address1: | 1701 LIBRARY BLVD STE A | ||||||||
| Address2: | |||||||||
| City: | GREENWOOD | ||||||||
| State: | IN | ||||||||
| PostalCode: | 461421567 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3178819923 | ||||||||
| FaxNumber: | 3178819966 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/05/2021 | ||||||||
| LastUpdateDate: | 02/05/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/05/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106S00000X | RBT-20-146492 | IN | Y |
No ID Information.