Provider Demographics
NPI:1467904714
Name:BROCKWAY, TERESA
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:
Last Name:BROCKWAY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8408 OLD EXCHANGE DR
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80920-4822
Mailing Address - Country:US
Mailing Address - Phone:719-393-3158
Mailing Address - Fax:719-218-9537
Practice Address - Street 1:8408 OLD EXCHANGE DR
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80920-4822
Practice Address - Country:US
Practice Address - Phone:719-393-3158
Practice Address - Fax:719-218-9537
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-02
Last Update Date:2016-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies