Provider Demographics
NPI:1780220426
Name:GREEN VALLEY PHYSICAL MEDICINE, INC
Entity Type:Organization
Organization Name:GREEN VALLEY PHYSICAL MEDICINE, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:CADE
Authorized Official - Last Name:BRODERICK
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:520-648-2225
Mailing Address - Street 1:380 W VISTA HERMOSA DR
Mailing Address - Street 2:
Mailing Address - City:GREEN VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:85614-1999
Mailing Address - Country:US
Mailing Address - Phone:520-648-2225
Mailing Address - Fax:520-625-9777
Practice Address - Street 1:380 W VISTA HERMOSA DR
Practice Address - Street 2:
Practice Address - City:GREEN VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:85614-1999
Practice Address - Country:US
Practice Address - Phone:520-648-2225
Practice Address - Fax:520-625-9777
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-11-18
Last Update Date:2019-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty