Provider Demographics
NPI:1407499387
Name:BROGAN, SANDY
Entity Type:Individual
Prefix:
First Name:SANDY
Middle Name:
Last Name:BROGAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4161 TAMIAMI TRL STE 704
Mailing Address - Street 2:
Mailing Address - City:PORT CHARLOTTE
Mailing Address - State:FL
Mailing Address - Zip Code:33952-9283
Mailing Address - Country:US
Mailing Address - Phone:941-625-1110
Mailing Address - Fax:
Practice Address - Street 1:4161 TAMIAMI TRAIL
Practice Address - Street 2:UNIT 704
Practice Address - City:PORT CHARLOTTE
Practice Address - State:FL
Practice Address - Zip Code:33952-9283
Practice Address - Country:US
Practice Address - Phone:941-625-1110
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-23
Last Update Date:2019-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA29316261QR0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0401XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Comprehensive Outpatient Rehabilitation Facility (CORF)