Provider Demographics
NPI:1366999260
Name:BROCK, BILLIE (RN,BSN)
Entity type:Individual
Prefix:
First Name:BILLIE
Middle Name:
Last Name:BROCK
Suffix:
Gender:F
Credentials:RN,BSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29 MCENTIRE ST
Mailing Address - Street 2:
Mailing Address - City:CARNESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30521-4083
Mailing Address - Country:US
Mailing Address - Phone:706-384-2082
Mailing Address - Fax:706-384-2083
Practice Address - Street 1:29 MCENTIRE ST
Practice Address - Street 2:
Practice Address - City:CARNESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30521-4083
Practice Address - Country:US
Practice Address - Phone:706-384-2082
Practice Address - Fax:706-384-2083
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-08
Last Update Date:2016-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA059-03-003-1310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility