Healthcare Provider Details

I. General information

NPI: 1609754613
Provider Name (Legal Business Name): JUSTUS DILLION BOCK
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/26/2025
Last Update Date: 08/26/2025
Certification Date: 08/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1110 PENNSYLVANIA ST NE STE B
ALBUQUERQUE NM
87110-7404
US

IV. Provider business mailing address

8309 GROUNDSEL RD NW
ALBUQUERQUE NM
87120-4238
US

V. Phone/Fax

Practice location:
  • Phone: 505-265-0753
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: