Healthcare Provider Details

I. General information

NPI: 1245986454
Provider Name (Legal Business Name): SILEAH BROCK CPM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/25/2022
Last Update Date: 02/25/2022
Certification Date: 02/24/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

202 1ST AVE SE
CULLMAN AL
35055-3449
US

IV. Provider business mailing address

1102 COUNTY ROAD 1225
VINEMONT AL
35179-6415
US

V. Phone/Fax

Practice location:
  • Phone: 256-531-5379
  • Fax:
Mailing address:
  • Phone: 256-531-5379
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code176B00000X
TaxonomyMidwife
License NumberLM0014
License Number StateAL

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: