Provider Demographics
NPI:1265640353
Name:BLOCK, TIMOTHY MICHAEL (ATC, PTA)
Entity Type:Individual
Prefix:MR
First Name:TIMOTHY
Middle Name:MICHAEL
Last Name:BLOCK
Suffix:
Gender:M
Credentials:ATC, PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 PARK LANE CT
Mailing Address - Street 2:
Mailing Address - City:ELDRIDGE
Mailing Address - State:IA
Mailing Address - Zip Code:52748-9676
Mailing Address - Country:US
Mailing Address - Phone:563-249-0162
Mailing Address - Fax:563-441-7796
Practice Address - Street 1:3385 DEXTER CT
Practice Address - Street 2:SUITE 301
Practice Address - City:DAVENPORT
Practice Address - State:IA
Practice Address - Zip Code:52807-3471
Practice Address - Country:US
Practice Address - Phone:563-344-6645
Practice Address - Fax:563-441-7796
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-20
Last Update Date:2012-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA002832255A2300X
IA004964225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant