Healthcare Provider Details

I. General information

NPI: 1649120650
Provider Name (Legal Business Name): BROCK BENJAMIN THOMAS CEO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/29/2026
Last Update Date: 01/29/2026
Certification Date: 01/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PO BOX 194
CANDO ND
58324-0194
US

IV. Provider business mailing address

PO BOX 194
CANDO ND
58324-0194
US

V. Phone/Fax

Practice location:
  • Phone: 701-946-4113
  • Fax:
Mailing address:
  • Phone: 701-946-4113
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code347C00000X
TaxonomyPrivate Vehicle
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: