Provider Demographics
NPI:1992397178
Name:WILLIAMS, BROCK
Entity Type:Individual
Prefix:
First Name:BROCK
Middle Name:
Last Name:WILLIAMS
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 1:8087 POWELL AVE
Mailing Address - Street 2:
Mailing Address - City:STONEWOOD
Mailing Address - State:WV
Mailing Address - Zip Code:26301-8036
Mailing Address - Country:US
Mailing Address - Phone:304-476-6740
Mailing Address - Fax:
Practice Address - Street 1:8087 POWELL AVE
Practice Address - Street 2:
Practice Address - City:STONEWOOD
Practice Address - State:WV
Practice Address - Zip Code:26301-8036
Practice Address - Country:US
Practice Address - Phone:304-476-6740
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-09
Last Update Date:2021-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker