Provider Demographics
NPI:1710546361
Name:SPOCK, THOMAS III (ATC)
Entity Type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:
Last Name:SPOCK
Suffix:III
Gender:M
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:PO BOX 6665
Mailing Address - Street 2:
Mailing Address - City:SAINT LEO
Mailing Address - State:FL
Mailing Address - Zip Code:33574-6665
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:33701 STATE ROAD 52
Practice Address - Street 2:
Practice Address - City:SAINT LEO
Practice Address - State:FL
Practice Address - Zip Code:33574
Practice Address - Country:US
Practice Address - Phone:352-588-8112
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-07
Last Update Date:2019-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL45412255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer