Basic Information
| Provider Information | |||||||||
| NPI: | 1023392693 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BROCK | ||||||||
| FirstName: | RAYME | ||||||||
| MiddleName: | MICHAEL | ||||||||
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| Credential: | R.N. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 341 THE VLG | ||||||||
| Address2: | |||||||||
| City: | REDONDO BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 902772652 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3108088289 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1224 N VINE ST | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900381612 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3237696100 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/30/2011 | ||||||||
| LastUpdateDate: | 09/30/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WP0808X | 586605 | CA | Y | Nursing Service Providers | Registered Nurse | Psych/Mental Health |
No ID Information.