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General NPI Number Information
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NPI Number | 1013364710
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Entity Type | Organization
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Legal Business Name | DALE W BROCK
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Dates
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Enumeration Date | 05/23/2016
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Last Update Date | 05/23/2016
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Provider Practice Location Address
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Address Line | 2800 BEAUMONT AVE SUITE A
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City | LIBERTY
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State | TX
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Zip | 77575-5126
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Country | US
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Telephone | 936-336-3100
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Fax | 936-336-3102
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Provider Business Mailing Address
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Address Line | 2800 BEAUMONT AVE SUITE A
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City | LIBERTY
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State | TX
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Zip | 77575-5126
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Country | US
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Telephone | 936-336-3100
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Fax | 936-336-3102
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Authorized Official
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Title or Position | OWNER
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Name | DALE W BROCK
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Credential | APN
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Telephone | 936-336-3100
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363L00000X
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Taxonomy Name | Nurse Practitioner
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License Number | 603165
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License Number State | TX
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