Provider Demographics
NPI:1275716839
Name:E DALE BROCK OD PC
Entity Type:Organization
Organization Name:E DALE BROCK OD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ERNEST
Authorized Official - Middle Name:DALE
Authorized Official - Last Name:BROCK
Authorized Official - Suffix:
Authorized Official - Credentials:OD PC
Authorized Official - Phone:618-937-3126
Mailing Address - Street 1:202 E CLARK ST
Mailing Address - Street 2:
Mailing Address - City:WEST FRANKFORT
Mailing Address - State:IL
Mailing Address - Zip Code:62896-2706
Mailing Address - Country:US
Mailing Address - Phone:618-937-3126
Mailing Address - Fax:618-937-3344
Practice Address - Street 1:202 E CLARK ST
Practice Address - Street 2:
Practice Address - City:WEST FRANKFORT
Practice Address - State:IL
Practice Address - Zip Code:62896-2706
Practice Address - Country:US
Practice Address - Phone:618-937-3126
Practice Address - Fax:618-937-3344
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-06
Last Update Date:2009-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL234570Medicare UPIN
IL0705620001Medicare NSC