Provider Demographics
NPI:1952893703
Name:BROCKBANK FOOT & ANKLE CLINIC PC
Entity Type:Organization
Organization Name:BROCKBANK FOOT & ANKLE CLINIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GREG
Authorized Official - Middle Name:
Authorized Official - Last Name:BROCKBANK
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:509-868-5865
Mailing Address - Street 1:9690 S 1300 E STE 120
Mailing Address - Street 2:
Mailing Address - City:SANDY
Mailing Address - State:UT
Mailing Address - Zip Code:84094-3798
Mailing Address - Country:US
Mailing Address - Phone:801-501-4335
Mailing Address - Fax:801-501-4338
Practice Address - Street 1:9690 S 1300 E STE 120
Practice Address - Street 2:
Practice Address - City:SANDY
Practice Address - State:UT
Practice Address - Zip Code:84094-3798
Practice Address - Country:US
Practice Address - Phone:801-501-4335
Practice Address - Fax:801-501-4338
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-06
Last Update Date:2018-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT356685-0501261QP1100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP1100XAmbulatory Health Care FacilitiesClinic/CenterPodiatric