Healthcare Provider Details

I. General information

NPI: 1437422425
Provider Name (Legal Business Name): SUN VALLEY MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/22/2012
Last Update Date: 02/22/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17215 N 72ND DR SUITE C-125
GLENDALE AZ
85308-8558
US

IV. Provider business mailing address

17215 N 72ND DR SUITE C-125
GLENDALE AZ
85308-8558
US

V. Phone/Fax

Practice location:
  • Phone: 623-935-7788
  • Fax:
Mailing address:
  • Phone: 623-935-7788
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number4105
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number5917
License Number StateAZ
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number4105
License Number StateAZ

VIII. Authorized Official

Name: AARON DEGROOT
Title or Position: OWNER
Credential:
Phone: 623-935-7788