Provider Demographics
NPI:1376747055
Name:BROCK, MELINDA (RD)
Entity Type:Individual
Prefix:
First Name:MELINDA
Middle Name:
Last Name:BROCK
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 17TH ST.
Mailing Address - Street 2:
Mailing Address - City:WOODWARD
Mailing Address - State:OK
Mailing Address - Zip Code:73801
Mailing Address - Country:US
Mailing Address - Phone:580-254-8456
Mailing Address - Fax:580-254-8457
Practice Address - Street 1:900 17TH ST.
Practice Address - Street 2:
Practice Address - City:WOODWARD
Practice Address - State:OK
Practice Address - Zip Code:73801
Practice Address - Country:US
Practice Address - Phone:580-254-8456
Practice Address - Fax:580-254-8457
Is Sole Proprietor?:No
Enumeration Date:2007-06-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKLD939133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered