Healthcare Provider Details

I. General information

NPI: 1972116002
Provider Name (Legal Business Name): DEREK LEWIS BROCKMAN DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/28/2020
Last Update Date: 08/28/2020
Certification Date: 08/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

102 W MAPLE ST
SCOTTSVILLE KY
42164-1134
US

IV. Provider business mailing address

PO BOX 2697
BOWLING GREEN KY
42102-7697
US

V. Phone/Fax

Practice location:
  • Phone: 270-239-6640
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number007992
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: