Provider Demographics
NPI:1083850861
Name:BROCK, GAIL C (LMT)
Entity Type:Individual
Prefix:MRS
First Name:GAIL
Middle Name:C
Last Name:BROCK
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 4197
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29608-4197
Mailing Address - Country:US
Mailing Address - Phone:864-616-9918
Mailing Address - Fax:
Practice Address - Street 1:112 AIRPORT RD
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29607-2607
Practice Address - Country:US
Practice Address - Phone:864-616-9918
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-27
Last Update Date:2008-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3343225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist