Provider Demographics
NPI:1528833837
Name:BROCKMAN, MORGAINE (LAC)
Entity type:Individual
Prefix:
First Name:MORGAINE
Middle Name:
Last Name:BROCKMAN
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2504 RIDGE RD STE 104
Mailing Address - Street 2:
Mailing Address - City:ROCKWALL
Mailing Address - State:TX
Mailing Address - Zip Code:75087-2570
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2504 RIDGE RD STE 104
Practice Address - Street 2:
Practice Address - City:ROCKWALL
Practice Address - State:TX
Practice Address - Zip Code:75087-2570
Practice Address - Country:US
Practice Address - Phone:972-813-9414
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-16
Last Update Date:2023-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAC02050171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist