Provider Demographics
NPI:1790835221
Name:MITCHELL, BROCK
Entity Type:Individual
Prefix:
First Name:BROCK
Middle Name:
Last Name:MITCHELL
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 1:53435 EAGLE RIDGE CT
Mailing Address - Street 2:
Mailing Address - City:NEW LONDON
Mailing Address - State:MO
Mailing Address - Zip Code:63459-2431
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:710 S BUSINESS 61
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:MO
Practice Address - Zip Code:63334-5239
Practice Address - Country:US
Practice Address - Phone:573-324-6079
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO117923225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist