Healthcare Provider Details

I. General information

NPI: 1306522875
Provider Name (Legal Business Name): SANDRA MAGANA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/27/2023
Last Update Date: 06/27/2023
Certification Date: 06/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1969 W OGDEN AVE
CHICAGO IL
60612
US

IV. Provider business mailing address

1323 W 19TH ST
CHICAGO IL
60608-5155
US

V. Phone/Fax

Practice location:
  • Phone: 312-864-6000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number160009656
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: