Provider Demographics
NPI:1710108121
Name:BOCK, DAVID RICHARD (CACDIPLOM,FABORM)
Entity Type:Individual
Prefix:MR
First Name:DAVID
Middle Name:RICHARD
Last Name:BOCK
Suffix:
Gender:M
Credentials:CACDIPLOM,FABORM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:888 THACKERAY TRL STE 206
Mailing Address - Street 2:
Mailing Address - City:OCONOMOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:53066-4342
Mailing Address - Country:US
Mailing Address - Phone:262-567-1309
Mailing Address - Fax:
Practice Address - Street 1:888 THACKERAY TRL STE 206
Practice Address - Street 2:
Practice Address - City:OCONOMOWOC
Practice Address - State:WI
Practice Address - Zip Code:53066-4342
Practice Address - Country:US
Practice Address - Phone:262-567-1309
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-01
Last Update Date:2011-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI263-055171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist