Healthcare Provider Details

I. General information

NPI: 1609599158
Provider Name (Legal Business Name): MARK ROCK
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/20/2022
Last Update Date: 09/20/2022
Certification Date: 09/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

284 BROADWAY AVE
YOUNGSTOWN OH
44504-1752
US

IV. Provider business mailing address

284 BROADWAY AVE
YOUNGSTOWN OH
44504-1752
US

V. Phone/Fax

Practice location:
  • Phone: 330-782-5664
  • Fax: 330-782-1614
Mailing address:
  • Phone: 330-782-5664
  • Fax: 330-782-1614

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberS.2208149
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: