Healthcare Provider Details

I. General information

NPI: 1205341880
Provider Name (Legal Business Name): BROCK WARD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/05/2017
Last Update Date: 12/05/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

109 HOMEWOOD BLVD
GLASGOW KY
42141-3468
US

IV. Provider business mailing address

308 MAPLE ST
HORSE CAVE KY
42749-1225
US

V. Phone/Fax

Practice location:
  • Phone: 270-651-6126
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: