Provider Demographics
NPI:1083915714
Name:BRODERICK, TAMI (RD)
Entity Type:Individual
Prefix:
First Name:TAMI
Middle Name:
Last Name:BRODERICK
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5181 ARGOSY AVE
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92649-1058
Mailing Address - Country:US
Mailing Address - Phone:714-624-7700
Mailing Address - Fax:714-602-1636
Practice Address - Street 1:436 HELIOTROPE AVE
Practice Address - Street 2:SUITE 2B
Practice Address - City:CORONA DEL MAR
Practice Address - State:CA
Practice Address - Zip Code:92625-2911
Practice Address - Country:US
Practice Address - Phone:949-723-9533
Practice Address - Fax:714-602-1636
Is Sole Proprietor?:No
Enumeration Date:2010-11-11
Last Update Date:2010-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA954681133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered