Healthcare Provider Details

I. General information

NPI: 1760101141
Provider Name (Legal Business Name): BROCK HARKINS ESAROVE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/26/2022
Last Update Date: 08/26/2022
Certification Date: 08/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1930 CROWN PARK CT STE 100
COLUMBUS OH
43235-2402
US

IV. Provider business mailing address

1930 CROWN PARK CT STE 100
COLUMBUS OH
43235-2402
US

V. Phone/Fax

Practice location:
  • Phone: 614-695-3747
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number757107
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: