=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255563490
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | PETER BROCK MSED, ATC, LAT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/21/2009
-----------------------------------------------------
Last Update Date | 08/22/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1201 WESLEYAN STREET
-----------------------------------------------------
City | FORT WORTH
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76105-1215
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-531-7590
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1201 WESLEYAN ST
-----------------------------------------------------
City | FT WORTH
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76105-1536
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-531-7590
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2255A2300X
-----------------------------------------------------
Taxonomy Name | Athletic Trainer
-----------------------------------------------------
License Number | AT4498
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------