Provider Demographics
NPI:1932313830
Name:REGINA P. BROCKMAN, D.C., PLLC
Entity Type:Organization
Organization Name:REGINA P. BROCKMAN, D.C., PLLC
Other - Org Name:BROCKMAN CHIROPRACTIC, PLLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:REGINA
Authorized Official - Middle Name:P
Authorized Official - Last Name:BROCKMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:859-336-8446
Mailing Address - Street 1:PO BOX 327
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:KY
Mailing Address - Zip Code:40069-0327
Mailing Address - Country:US
Mailing Address - Phone:859-336-8446
Mailing Address - Fax:
Practice Address - Street 1:3951 BARDSTOWN RD
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:KY
Practice Address - Zip Code:40069-8450
Practice Address - Country:US
Practice Address - Phone:859-336-8446
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-09
Last Update Date:2011-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY4174111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY2719881000OtherPASSPORT ADV. GROUP
KY2448139000OtherPASSPORT ADVANTAGE PROVID
KY50010765OtherPASSPORT HLTH GRP#
KY50006949OtherPASSPORT HLTH PROV#
KY7302Medicare ID - Type UnspecifiedGROUP NUMBER
KY0730201Medicare ID - Type UnspecifiedPROVIDER NUMBEER
KY50010765OtherPASSPORT HLTH GRP#