Healthcare Provider Details

I. General information

NPI: 1043029192
Provider Name (Legal Business Name): BROCK TISSUES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/03/2025
Last Update Date: 01/03/2025
Certification Date: 01/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

212 FOX HILL RD
ATHENS ME
04912-4719
US

IV. Provider business mailing address

212 FOX HILL RD
ATHENS ME
04912-4719
US

V. Phone/Fax

Practice location:
  • Phone: 207-654-2713
  • Fax:
Mailing address:
  • Phone: 207-654-2713
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number State

VIII. Authorized Official

Name: KELLY WESBROCK
Title or Position: CHIEF EXECUTIVE OFFICER
Credential:
Phone: 207-691-5059