Healthcare Provider Details

I. General information

NPI: 1821874207
Provider Name (Legal Business Name): BROCK GOMER PT, DPT, ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/01/2023
Last Update Date: 09/01/2023
Certification Date: 09/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4200 32ND AVE S
FARGO ND
58104-8952
US

IV. Provider business mailing address

4200 32ND AVE S
FARGO ND
58104-8952
US

V. Phone/Fax

Practice location:
  • Phone: 701-234-8700
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number2646
License Number StateND

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: