Provider Demographics
NPI:1194487546
Name:BROCK, VIKKI L (PTA)
Entity Type:Individual
Prefix:
First Name:VIKKI
Middle Name:L
Last Name:BROCK
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:VIKKI
Other - Middle Name:LEE
Other - Last Name:LYDON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1202 W NILE ST
Mailing Address - Street 2:
Mailing Address - City:CORBIN
Mailing Address - State:KY
Mailing Address - Zip Code:40701-2609
Mailing Address - Country:US
Mailing Address - Phone:606-261-5382
Mailing Address - Fax:
Practice Address - Street 1:1202 W NILE ST
Practice Address - Street 2:
Practice Address - City:CORBIN
Practice Address - State:KY
Practice Address - Zip Code:40701-2609
Practice Address - Country:US
Practice Address - Phone:606-261-5382
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-12
Last Update Date:2021-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYA01430208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation