Provider Demographics
NPI:1265190821
Name:FORD, BROCK ALLEN (PT,DPT)
Entity type:Individual
Prefix:DR
First Name:BROCK
Middle Name:ALLEN
Last Name:FORD
Suffix:
Gender:M
Credentials:PT,DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2548 S 900 E
Mailing Address - Street 2:
Mailing Address - City:GREENTOWN
Mailing Address - State:IN
Mailing Address - Zip Code:46936-9204
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:705 N MERIDIAN ST
Practice Address - Street 2:
Practice Address - City:GREENTOWN
Practice Address - State:IN
Practice Address - Zip Code:46936-1246
Practice Address - Country:US
Practice Address - Phone:765-628-3377
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-01
Last Update Date:2021-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05013068A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NONEOtherNONE