MEDICARE: MRS. REYFANETTE BROUGHTON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	335E00000X	Prosthetic/Orthotic Supplier

General Provider Information

NPI Number	:	1255141834
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. REYFANETTE BROUGHTON

Provider Business Mailing Address
First Line	:	128 S EAST ST UNIT 555
Second Line	:
City	:	CROWN POINT
State	:	IN
Zip	:	46307-4030
Country	:	US
Telephone Number	:	219-424-2888
Fax Number	:

Provider Business Practice Location Address
First Line	:	2505 HARVEST DR
Second Line	:
City	:	CROWN POINT
State	:	IN
Zip	:	46307-9679
Country	:	US
Telephone Number	:	219-424-2888
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/07/2025
Last Update Date	:	01/07/2025

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Directions to “ MRS. REYFANETTE BROUGHTON ” Practice Location

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