Provider Demographics
NPI:1528360658
Name:BROADDUS, PARKER S
Entity Type:Individual
Prefix:
First Name:PARKER
Middle Name:S
Last Name:BROADDUS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 HIGHWAY 60
Mailing Address - Street 2:
Mailing Address - City:SOCORRO
Mailing Address - State:NM
Mailing Address - Zip Code:87801-3914
Mailing Address - Country:US
Mailing Address - Phone:575-835-2444
Mailing Address - Fax:575-838-0150
Practice Address - Street 1:1200 HIGHWAY 60
Practice Address - Street 2:
Practice Address - City:SOCORRO
Practice Address - State:NM
Practice Address - Zip Code:87801-3914
Practice Address - Country:US
Practice Address - Phone:575-835-2444
Practice Address - Fax:575-838-0150
Is Sole Proprietor?:No
Enumeration Date:2010-11-22
Last Update Date:2010-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator