Provider Demographics
NPI:1306493309
Name:BULLOCK, KENNETH
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:
Last Name:BULLOCK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:710 S BROADWAY STE 250
Mailing Address - Street 2:
Mailing Address - City:WALNUT CREEK
Mailing Address - State:CA
Mailing Address - Zip Code:94596-5234
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:550 PATTERSON BLVD
Practice Address - Street 2:
Practice Address - City:PLEASANT HILL
Practice Address - State:CA
Practice Address - Zip Code:94523-4155
Practice Address - Country:US
Practice Address - Phone:925-938-8050
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-23
Last Update Date:2023-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker