Provider Demographics
NPI:1013364710
Name:DALE W BROCK
Entity Type:Organization
Organization Name:DALE W BROCK
Other - Org Name:TRINITY VALLEY CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DALE
Authorized Official - Middle Name:W
Authorized Official - Last Name:BROCK
Authorized Official - Suffix:
Authorized Official - Credentials:APN
Authorized Official - Phone:936-336-3100
Mailing Address - Street 1:2800 BEAUMONT AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:LIBERTY
Mailing Address - State:TX
Mailing Address - Zip Code:77575-5126
Mailing Address - Country:US
Mailing Address - Phone:936-336-3100
Mailing Address - Fax:936-336-3102
Practice Address - Street 1:2800 BEAUMONT AVE
Practice Address - Street 2:SUITE A
Practice Address - City:LIBERTY
Practice Address - State:TX
Practice Address - Zip Code:77575-5126
Practice Address - Country:US
Practice Address - Phone:936-336-3100
Practice Address - Fax:936-336-3102
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-23
Last Update Date:2016-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX603165363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8F2993Medicare PIN
TXP41475Medicare UPIN