Provider Demographics
NPI:1821145400
Name:BROCK, LUTHER GREEN JR (CFTS, CFO)
Entity Type:Individual
Prefix:MR
First Name:LUTHER
Middle Name:GREEN
Last Name:BROCK
Suffix:JR
Gender:M
Credentials:CFTS, CFO
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 11348
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27116-1348
Mailing Address - Country:US
Mailing Address - Phone:336-896-0408
Mailing Address - Fax:336-896-0409
Practice Address - Street 1:8007 N POINT BLVD
Practice Address - Street 2:SUITE F
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27106-3268
Practice Address - Country:US
Practice Address - Phone:336-896-0408
Practice Address - Fax:336-896-0409
Is Sole Proprietor?:No
Enumeration Date:2007-01-04
Last Update Date:2013-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CFTS0684225000000X
CFO02049225000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225000000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotic Fitter
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7795387Medicaid
NC7795178Medicaid