Healthcare Provider Details

I. General information

NPI: 1437262185
Provider Name (Legal Business Name): KIM S. O'CONNELL-BROCK ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/16/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1815 WELLS STREET 2ND FLOOR
LAS CRUCES NM
88005
US

IV. Provider business mailing address

800 CHATEAU DR
LAS CRUCES NM
88005-1534
US

V. Phone/Fax

Practice location:
  • Phone: 505-646-5744
  • Fax:
Mailing address:
  • Phone: 505-647-5108
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number152
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: