1710222310 NPI number — DAVID JOSHUA BROCKBANK N.P.-C

Table of content: DAVID JOSHUA BROCKBANK N.P.-C (NPI 1710222310)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710222310 NPI number — DAVID JOSHUA BROCKBANK N.P.-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BROCKBANK
Provider First Name:
DAVID
Provider Middle Name:
JOSHUA
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
N.P.-C
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1710222310
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/21/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10433 S REDWOOD RD STE 2
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SOUTH JORDAN
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84095-8502
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
801-260-1919
Provider Business Mailing Address Fax Number:
801-260-1441

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3451 S. 5600 W.
Provider Second Line Business Practice Location Address:
SUITE F
Provider Business Practice Location Address City Name:
WVC
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84020
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-957-0900
Provider Business Practice Location Address Fax Number:
801-966-4984
Provider Enumeration Date:
12/07/2012

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363L00000X , with the licence number:  7034673-4405 , registered in the state of UT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LF0000X , with the licence number: 7034673-4405 , registered in the state of UT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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