Provider Demographics
NPI:1477089662
Name:BROCK LISTER PT PA
Entity Type:Organization
Organization Name:BROCK LISTER PT PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BROCK
Authorized Official - Middle Name:
Authorized Official - Last Name:LISTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:716-523-1783
Mailing Address - Street 1:2534 WOOD POINTE DR
Mailing Address - Street 2:
Mailing Address - City:HOLIDAY
Mailing Address - State:FL
Mailing Address - Zip Code:34691-7803
Mailing Address - Country:US
Mailing Address - Phone:716-523-1783
Mailing Address - Fax:
Practice Address - Street 1:2534 WOOD POINTE DR
Practice Address - Street 2:
Practice Address - City:HOLIDAY
Practice Address - State:FL
Practice Address - Zip Code:34691-7803
Practice Address - Country:US
Practice Address - Phone:716-523-1783
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-07
Last Update Date:2017-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL31894261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy