Provider Demographics
NPI:1437262185
Name:O'CONNELL-BROCK, KIM S (ATC)
Entity Type:Individual
Prefix:MS
First Name:KIM
Middle Name:S
Last Name:O'CONNELL-BROCK
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 CHATEAU DR
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88005-1534
Mailing Address - Country:US
Mailing Address - Phone:505-647-5108
Mailing Address - Fax:
Practice Address - Street 1:1815 WELLS STREET
Practice Address - Street 2:2ND FLOOR
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88005
Practice Address - Country:US
Practice Address - Phone:505-646-5744
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1522255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer