Provider Demographics
NPI:1063450054
Name:BROCK, WARNER (PT,CMDT, MBA, CEAS)
Entity Type:Individual
Prefix:
First Name:WARNER
Middle Name:
Last Name:BROCK
Suffix:
Gender:M
Credentials:PT,CMDT, MBA, CEAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 SPRING ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:GAINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30501-2565
Mailing Address - Country:US
Mailing Address - Phone:770-532-5721
Mailing Address - Fax:770-532-5929
Practice Address - Street 1:100 SPRING ST
Practice Address - Street 2:SUITE B
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30501-2565
Practice Address - Country:US
Practice Address - Phone:770-532-5721
Practice Address - Fax:770-532-5929
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA2651225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA65BBCTHMedicare ID - Type Unspecified
GAQ31751Medicare UPIN