MEDICARE: BRENT ADAM MORLOCK ATC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2255A2300X	Athletic Trainer	0126002385	VA

General Provider Information

NPI Number	:	1174056832
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRENT ADAM MORLOCK ATC

Provider Business Mailing Address
First Line	:	4716 RUGBY RD
Second Line	:
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23464-7959
Country	:	US
Telephone Number	:	757-372-1230
Fax Number	:

Provider Business Practice Location Address
First Line	:	4716 RUGBY RD
Second Line	:
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23464-7959
Country	:	US
Telephone Number	:	757-372-1230
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/09/2017
Last Update Date	:	04/09/2017

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