Healthcare Provider Details

I. General information

NPI: 1508907171
Provider Name (Legal Business Name): KAREN DALE BROCK CPM TN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/08/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25112 UNION HILL RD
ARDMORE TN
38449-3168
US

IV. Provider business mailing address

210 WILLINGHAM DR
CULLMAN AL
35055-3183
US

V. Phone/Fax

Practice location:
  • Phone: 931-427-3726
  • Fax:
Mailing address:
  • Phone: 256-734-4593
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code176B00000X
TaxonomyMidwife
License NumberCPM0000000022
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: