Provider Demographics
| NPI: | 1962817841 |
|---|---|
| Name: | BROCK, JEREMY (RRT, RCP) |
| Entity Type: | Individual |
| Prefix: | |
| First Name: | JEREMY |
| Middle Name: | |
| Last Name: | BROCK |
| Suffix: | |
| Gender: | M |
| Credentials: | RRT, RCP |
| Other - Prefix: | |
| Other - First Name: | JEREMY |
| Other - Middle Name: | |
| Other - Last Name: | BROCK |
| Other - Suffix: | |
| Other - Last Name Type: | Professional Name |
| Other - Credentials: | RRT |
| Mailing Address - Street 1: | 105 PHEASANT RIDGE DR |
| Mailing Address - Street 2: | |
| Mailing Address - City: | WARNER ROBINS |
| Mailing Address - State: | GA |
| Mailing Address - Zip Code: | 31088-6563 |
| Mailing Address - Country: | US |
| Mailing Address - Phone: | 478-955-9370 |
| Mailing Address - Fax: | |
| Practice Address - Street 1: | 8415 DATAPOINT DR. |
| Practice Address - Street 2: | PARALLON WORKFORCE MANAGEMENT SOLUTIONS |
| Practice Address - City: | SAN ANTONIO |
| Practice Address - State: | TX |
| Practice Address - Zip Code: | 78229 |
| Practice Address - Country: | US |
| Practice Address - Phone: | 210-593-0570 |
| Practice Address - Fax: | |
| Is Sole Proprietor?: | No |
| Enumeration Date: | 2014-06-30 |
| Last Update Date: | 2014-06-30 |
| Deactivation Date: | |
| Deactivation Code: | |
| Reactivation Date: |
Provider Licenses
| State | License ID | Taxonomies |
|---|---|---|
| TX | 76227 | 227900000X, 2279E0002X, 2279E1000X, 2279G1100X, 2279P1004X |
| TX | 76627 | 2279C0205X |
Provider Taxonomies
| Primary? | Code | Type | Classification | Specialization |
|---|---|---|---|---|
| Yes | 227900000X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Respiratory Therapist, Registered | |
| No | 2279C0205X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Respiratory Therapist, Registered | Critical Care |
| No | 2279E0002X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Respiratory Therapist, Registered | Emergency Care |
| No | 2279E1000X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Respiratory Therapist, Registered | Educational |
| No | 2279G1100X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Respiratory Therapist, Registered | General Care |
| No | 2279P1004X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Respiratory Therapist, Registered | Pulmonary Diagnostics |
