Basic Information
| Provider Information | |||||||||
| NPI: | 1205955929 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BROCKINGTON | ||||||||
| FirstName: | RACQUEL | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2700 HAMLIN BLVD | ||||||||
| Address2: | |||||||||
| City: | INKSTER | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481412206 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7349414991 | ||||||||
| FaxNumber: | 7349414919 | ||||||||
| Practice Location | |||||||||
| Address1: | 2151 E JEFFERSON AVE | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482074161 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3132597990 | ||||||||
| FaxNumber: | 3132597294 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/28/2007 | ||||||||
| LastUpdateDate: | 07/28/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 5101013595 | MI | Y | Allopathic & Osteopathic Physicians | Family Medicine | 2083X0100X | 5101013595 | MI | N | Allopathic & Osteopathic Physicians | Preventive Medicine | Occupational Medicine |
No ID Information.