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General NPI Number Information
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NPI Number | 1407499387
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Entity Type | Individual
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Provider Name | SANDY BROGAN
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Gender | Female
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Dates
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Enumeration Date | 10/23/2019
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Last Update Date | 10/23/2019
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Provider Practice Location Address
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Address Line | 4161 TAMIAMI TRAIL UNIT 704
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City | PORT CHARLOTTE
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State | FL
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Zip | 33952-9283
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Country | US
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Telephone | 941-625-1110
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Fax |
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Provider Business Mailing Address
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Address Line | 4161 TAMIAMI TRL STE 704
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City | PORT CHARLOTTE
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State | FL
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Zip | 33952-9283
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Country | US
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Telephone | 941-625-1110
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QR0401X
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Taxonomy Name | Comprehensive Outpatient Rehabilitation Facility (CORF)
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License Number | PTA29316
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License Number State | FL
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