Healthcare Provider Details

I. General information

NPI: 1770748188
Provider Name (Legal Business Name): SANJUANA BRODEN PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/24/2008
Last Update Date: 07/24/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1221 W 56TH AVE
MERRILLVILLE IN
46410-1903
US

IV. Provider business mailing address

1221 W 56TH AVE
MERRILLVILLE IN
46410-1903
US

V. Phone/Fax

Practice location:
  • Phone: 219-887-0063
  • Fax:
Mailing address:
  • Phone: 219-887-0063
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number06002889A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: