Provider Demographics
NPI:1740602432
Name:BOCK, SUMMER SUNSHINE (LMT)
Entity Type:Individual
Prefix:
First Name:SUMMER
Middle Name:SUNSHINE
Last Name:BOCK
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:525 ROSE ST NE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97301-4473
Mailing Address - Country:US
Mailing Address - Phone:503-507-0693
Mailing Address - Fax:503-400-7956
Practice Address - Street 1:2975 RIVER RD S
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97302-9754
Practice Address - Country:US
Practice Address - Phone:503-507-0693
Practice Address - Fax:503-400-7956
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-14
Last Update Date:2014-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR19475172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker