Provider Demographics
NPI:1861414138
Name:BROCKMAN, MARJORIE A (RN, DC, C AC)
Entity type:Individual
Prefix:
First Name:MARJORIE
Middle Name:A
Last Name:BROCKMAN
Suffix:
Gender:F
Credentials:RN, DC, C AC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:445 IDAHO ST
Mailing Address - Street 2:
Mailing Address - City:GOODING
Mailing Address - State:ID
Mailing Address - Zip Code:83330-1258
Mailing Address - Country:US
Mailing Address - Phone:208-934-5000
Mailing Address - Fax:208-934-5284
Practice Address - Street 1:445 IDAHO ST
Practice Address - Street 2:
Practice Address - City:GOODING
Practice Address - State:ID
Practice Address - Zip Code:83330-1258
Practice Address - Country:US
Practice Address - Phone:208-934-5000
Practice Address - Fax:208-934-5284
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDCHIA-749111N00000X
IDACC66171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered111N00000XChiropractic ProvidersChiropractor
Not Answered171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000010023081OtherBLUE SHIELD PROVIDER #
IDC-7499OtherBLUE CROSS PROVIDER NUM
IDU54567Medicare UPIN
ID000010023081OtherBLUE SHIELD PROVIDER #