Healthcare Provider Details

I. General information

NPI: 1265190821
Provider Name (Legal Business Name): BROCK ALLEN FORD PT,DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/01/2021
Last Update Date: 12/01/2021
Certification Date: 12/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

705 N MERIDIAN ST
GREENTOWN IN
46936-1246
US

IV. Provider business mailing address

2548 S 900 E
GREENTOWN IN
46936-9204
US

V. Phone/Fax

Practice location:
  • Phone: 765-628-3377
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number05013068A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: