Healthcare Provider Details

I. General information

NPI: 1871108233
Provider Name (Legal Business Name): RICKY BROCKINGTON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/12/2020
Last Update Date: 08/12/2021
Certification Date: 08/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

102 FAIRVIEW DR STE B
FRANKLIN VA
23851-1206
US

IV. Provider business mailing address

19124 LAKESIDE DR
COURTLAND VA
23837-2634
US

V. Phone/Fax

Practice location:
  • Phone: 757-562-2158
  • Fax: 757-516-8019
Mailing address:
  • Phone: 757-562-2004
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number0024180104
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: