Healthcare Provider Details

I. General information

NPI: 1922055292
Provider Name (Legal Business Name): DALE WAYNE BROCK APN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/30/2006
Last Update Date: 07/15/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2718A N MAIN ST
LIBERTY TX
77575-3909
US

IV. Provider business mailing address

2718A N MAIN ST
LIBERTY TX
77575-3909
US

V. Phone/Fax

Practice location:
  • Phone: 936-336-3616
  • Fax:
Mailing address:
  • Phone: 936-336-3616
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number603165
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number603165
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: