Healthcare Provider Details

I. General information

NPI: 1104810001
Provider Name (Legal Business Name): GEORGE BRADLEY KLOCK DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: G BRADLEY KLOCK DO PC

II. Dates (important events)

Enumeration Date: 09/07/2005
Last Update Date: 05/23/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3200 GRAND AVE
DES MOINES IA
50312-4104
US

IV. Provider business mailing address

3200 GRAND AVE
DES MOINES IA
50312-4104
US

V. Phone/Fax

Practice location:
  • Phone: 515-271-1722
  • Fax: 515-271-1697
Mailing address:
  • Phone: 515-271-1722
  • Fax: 515-271-1697

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code204D00000X
TaxonomyNeuromusculoskeletal Medicine & OMM Physician
License Number1890
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code204D00000X
TaxonomyNeuromusculoskeletal Medicine & OMM Physician
License Number1998
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: