Provider Demographics
NPI:1427575224
Name:BROCK, DAVID
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:BROCK
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 1:106 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SPRING ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:49283-9701
Mailing Address - Country:US
Mailing Address - Phone:248-760-3641
Mailing Address - Fax:
Practice Address - Street 1:106 E MAIN ST.
Practice Address - Street 2:
Practice Address - City:SPRING ARBOR
Practice Address - State:MI
Practice Address - Zip Code:49283
Practice Address - Country:US
Practice Address - Phone:248-760-3641
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-23
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI26010001702255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2601000170OtherSPORTS MEDICINE