Provider Demographics
NPI:1902617038
Name:BROCK, BURCHELL JR
Entity type:Individual
Prefix:
First Name:BURCHELL
Middle Name:
Last Name:BROCK
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:124 S 3RD ST
Mailing Address - Street 2:
Mailing Address - City:CARDINGTON
Mailing Address - State:OH
Mailing Address - Zip Code:43315-1082
Mailing Address - Country:US
Mailing Address - Phone:614-625-5585
Mailing Address - Fax:
Practice Address - Street 1:124 S 3RD ST
Practice Address - Street 2:
Practice Address - City:CARDINGTON
Practice Address - State:OH
Practice Address - Zip Code:43315-1082
Practice Address - Country:US
Practice Address - Phone:614-625-5585
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-17
Last Update Date:2025-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide