Provider Demographics
NPI:1881739555
Name:BROCKMAN, REGINA P (DC)
Entity type:Individual
Prefix:DR
First Name:REGINA
Middle Name:P
Last Name:BROCKMAN
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
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:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-21
Last Update Date:2011-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY4174111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY1220237OtherNGS
KY616822OtherACN
KY85003374Medicaid
KY50006949OtherPASSPORT HEALTH PLAN
KY000000256734OtherANTHEM
KY0269566OtherCIGNA
KY2448139000OtherPASSPORT ADVANTAGE
KY616822OtherACN
KY85003374Medicaid
KY0730201Medicare PIN