Healthcare Provider Details

I. General information

NPI: 1447816442
Provider Name (Legal Business Name): BROCK EDWARD HULSEY PT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/15/2019
Last Update Date: 07/25/2024
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

920 DEON DR STE D
POCATELLO ID
83201
US

IV. Provider business mailing address

920 DEON DR STE D
POCATELLO ID
83201
US

V. Phone/Fax

Practice location:
  • Phone: 208-425-1470
  • Fax: 208-425-1471
Mailing address:
  • Phone: 208-425-1470
  • Fax: 208-425-1471

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: