Provider Demographics
NPI:1235631052
Name:BROCKBERG, RICKY
Entity Type:Individual
Prefix:
First Name:RICKY
Middle Name:
Last Name:BROCKBERG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:931 MADISON AVE STE 203
Mailing Address - Street 2:
Mailing Address - City:MANKATO
Mailing Address - State:MN
Mailing Address - Zip Code:56001-6995
Mailing Address - Country:US
Mailing Address - Phone:507-344-8900
Mailing Address - Fax:
Practice Address - Street 1:931 MADISON AVE STE 203
Practice Address - Street 2:
Practice Address - City:MANKATO
Practice Address - State:MN
Practice Address - Zip Code:56001-6995
Practice Address - Country:US
Practice Address - Phone:507-344-8900
Practice Address - Fax:866-920-6333
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-07
Last Update Date:2021-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN382785343800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343800000XTransportation ServicesSecured Medical Transport (VAN)