Healthcare Provider Details

I. General information

NPI: 1215826912
Provider Name (Legal Business Name): BROCK KITCHEN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/30/2025
Last Update Date: 07/01/2025
Certification Date: 07/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 E STATE ST STE D
ATHENS OH
45701-1870
US

IV. Provider business mailing address

127 HITCHCOCK DR
SOUTH SHORE KY
41175-8020
US

V. Phone/Fax

Practice location:
  • Phone: 740-326-6110
  • Fax: 800-480-7578
Mailing address:
  • Phone: 740-456-7535
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: