Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 208100000X | Physical Medicine & Rehabilitation Doctor | 5502001181 | MI |
NPI | 1033762240 |
---|---|
Provider Name | Kristie Lyn Brock |
First Address | Salem, OR 97302-1691 |
Second Address | Salem, OR 97302-1691 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 17/07/2019 |
Last Update Date | 17/07/2019 |