Provider Demographics
NPI:1760081038
Name:BROCK, KENNETH SEAN
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:SEAN
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 1:1110 MARTIN AVE
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43612-1727
Mailing Address - Country:US
Mailing Address - Phone:937-830-1313
Mailing Address - Fax:
Practice Address - Street 1:1110 MARTIN AVE
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43612-1727
Practice Address - Country:US
Practice Address - Phone:937-830-1313
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-19
Last Update Date:2020-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide