Provider Demographics
NPI:1225620164
Name:KANE, BROCK
Entity Type:Individual
Prefix:
First Name:BROCK
Middle Name:
Last Name:KANE
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 1:705 HORICON ST UNIT 1
Mailing Address - Street 2:
Mailing Address - City:HORICON
Mailing Address - State:WI
Mailing Address - Zip Code:53032-2100
Mailing Address - Country:US
Mailing Address - Phone:920-210-4527
Mailing Address - Fax:
Practice Address - Street 1:705 HORICON ST UNIT 1
Practice Address - Street 2:
Practice Address - City:HORICON
Practice Address - State:WI
Practice Address - Zip Code:53032-2100
Practice Address - Country:US
Practice Address - Phone:920-210-4527
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-10
Last Update Date:2021-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide