Healthcare Provider Details

I. General information

NPI: 1205955929
Provider Name (Legal Business Name): RACQUEL BROCKINGTON DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/28/2007
Last Update Date: 07/24/2025
Certification Date: 07/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1601 E KALAMAZOO ST
LANSING MI
48912-2701
US

IV. Provider business mailing address

PO BOX 30161
LANSING MI
48909-7661
US

V. Phone/Fax

Practice location:
  • Phone: 517-679-2880
  • Fax:
Mailing address:
  • Phone: 517-887-4383
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2083X0100X
TaxonomyOccupational Medicine Physician
License Number5101013595
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number5101013595
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: