Provider Demographics
NPI:1144383753
Name:BROCK, DEAN RAY (DC)
Entity type:Individual
Prefix:DR
First Name:DEAN
Middle Name:RAY
Last Name:BROCK
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:402 N BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:TRUTH OR CONSEQUENCES
Mailing Address - State:NM
Mailing Address - Zip Code:87901-2836
Mailing Address - Country:US
Mailing Address - Phone:505-894-9355
Mailing Address - Fax:800-957-2330
Practice Address - Street 1:402 N BROADWAY ST
Practice Address - Street 2:
Practice Address - City:TRUTH OR CONSEQUENCES
Practice Address - State:NM
Practice Address - Zip Code:87901-2836
Practice Address - Country:US
Practice Address - Phone:505-894-9355
Practice Address - Fax:800-957-2330
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-18
Last Update Date:2012-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1493111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMU83804Medicare UPIN
NM9005521265Medicare ID - Type Unspecified