MEDICARE: DEBORAH LEE BROCK DIETICIAN

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	133V00000X	Registered Dietitian	KY-1184	KY

General Provider Information

NPI Number	:	1619920881
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DEBORAH LEE BROCK DIETICIAN

Provider Business Mailing Address
First Line	:	250 TOWNSEND VALLEY RD
Second Line	:
City	:	PARIS
State	:	KY
Zip	:	40361-9757
Country	:	US
Telephone Number	:	859-987-7249
Fax Number	:

Provider Business Practice Location Address
First Line	:	1210 KY HIGHWAY 36 E
Second Line	:
City	:	CYNTHIANA
State	:	KY
Zip	:	41031-7490
Country	:	US
Telephone Number	:	859-234-2300
Fax Number	:

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

Provider Enumeration Date	:	05/18/2006
Last Update Date	:	07/08/2007

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