Provider Demographics
NPI:1568940948
Name:BROCK, ETHAN MCCOY
Entity Type:Individual
Prefix:
First Name:ETHAN
Middle Name:MCCOY
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 1:113 MAYSVILLE SCHOOL RD
Mailing Address - Street 2:
Mailing Address - City:MOUNT OLIVE
Mailing Address - State:NC
Mailing Address - Zip Code:28365-6541
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:214 LANEFIELD RD
Practice Address - Street 2:
Practice Address - City:WARSAW
Practice Address - State:NC
Practice Address - Zip Code:28398-8719
Practice Address - Country:US
Practice Address - Phone:910-293-3144
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-30
Last Update Date:2018-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC6671225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant