Provider Demographics
NPI:1609415116
Name:DURLEY, BRODERICH ALEXANDER
Entity Type:Individual
Prefix:
First Name:BRODERICH
Middle Name:ALEXANDER
Last Name:DURLEY
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 1:14235 OAKLEY DR
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92503-7236
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:14235 OAKLEY DR
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92503-7236
Practice Address - Country:US
Practice Address - Phone:951-231-3916
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-31
Last Update Date:2019-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program