Provider Demographics
NPI:1821725615
Name:RENKEN, BROCK MICHAEL
Entity Type:Individual
Prefix:
First Name:BROCK
Middle Name:MICHAEL
Last Name:RENKEN
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 1:9718 N 44TH EAST AVE
Mailing Address - Street 2:
Mailing Address - City:SPERRY
Mailing Address - State:OK
Mailing Address - Zip Code:74073-4545
Mailing Address - Country:US
Mailing Address - Phone:417-499-2646
Mailing Address - Fax:
Practice Address - Street 1:9718 N 44TH EAST AVE
Practice Address - Street 2:
Practice Address - City:SPERRY
Practice Address - State:OK
Practice Address - Zip Code:74073-4545
Practice Address - Country:US
Practice Address - Phone:417-499-2646
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-02
Last Update Date:2022-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program