1437181088 NPI number — JULIE C. BROCK, O.D., INC.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1437181088 NPI number — JULIE C. BROCK, O.D., INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JULIE C. BROCK, O.D., INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1437181088
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1055
Provider Second Line Business Mailing Address:
107 TOWN CREEK DRIVE
Provider Business Mailing Address City Name:
SALTILLO
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
38866-1055
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
662-869-1779
Provider Business Mailing Address Fax Number:
662-869-3776

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
107 TOWN CREEK DRIVE
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
SALTILLO
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
38866
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
662-869-1779
Provider Business Practice Location Address Fax Number:
662-869-3776
Provider Enumeration Date:
07/06/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BROCK
Authorized Official First Name:
JULIE
Authorized Official Middle Name:
C.
Authorized Official Title or Position:
PRESIDENT/OWNER/PROVIDER
Authorized Official Telephone Number:
662-869-1779

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  661 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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