Provider Demographics
NPI:1093748980
Name:BROWN, REGINA MARIA
Entity Type:Individual
Prefix:
First Name:REGINA
Middle Name:MARIA
Last Name:BROWN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:REGINA
Other - Middle Name:MARIA
Other - Last Name:ROARK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DC
Mailing Address - Street 1:821 W SAN MARCOS BLVD
Mailing Address - Street 2:
Mailing Address - City:SAN MARCOS
Mailing Address - State:CA
Mailing Address - Zip Code:92078-1112
Mailing Address - Country:US
Mailing Address - Phone:760-591-4992
Mailing Address - Fax:
Practice Address - Street 1:821 W SAN MARCOS BLVD
Practice Address - Street 2:
Practice Address - City:SAN MARCOS
Practice Address - State:CA
Practice Address - Zip Code:92078-1112
Practice Address - Country:US
Practice Address - Phone:760-591-4992
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-07
Last Update Date:2015-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC22138111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAU40223Medicare UPIN
CADC22138Medicare ID - Type Unspecified