Provider Demographics
NPI:1962854182
Name:BROUGHTON, TRACEY MARTIN (RT)
Entity Type:Individual
Prefix:
First Name:TRACEY
Middle Name:MARTIN
Last Name:BROUGHTON
Suffix:
Gender:F
Credentials:RT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:127 S HERLONG AVE
Mailing Address - Street 2:
Mailing Address - City:ROCK HILL
Mailing Address - State:SC
Mailing Address - Zip Code:29732-1100
Mailing Address - Country:US
Mailing Address - Phone:803-327-8655
Mailing Address - Fax:803-327-0664
Practice Address - Street 1:127 S HERLONG AVE
Practice Address - Street 2:
Practice Address - City:ROCK HILL
Practice Address - State:SC
Practice Address - Zip Code:29732-1100
Practice Address - Country:US
Practice Address - Phone:803-327-8655
Practice Address - Fax:803-327-0664
Is Sole Proprietor?:No
Enumeration Date:2016-07-12
Last Update Date:2016-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3120227900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes227900000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRespiratory Therapist, Registered