MEDICARE: SUN VALLEY MEDICAL GROUP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111N00000X	Chiropractor	5917	AZ

General Provider Information

NPI Number	:	1871865741
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SUN VALLEY MEDICAL GROUP

Provider Business Mailing Address
First Line	:	17215 N 72ND DR
Second Line	:	SUITE C-125
City	:	GLENDALE
State	:	AZ
Zip	:	85308-8558
Country	:	US
Telephone Number	:	623-935-7788
Fax Number	:

Provider Business Practice Location Address
First Line	:	13020 W RANCHO SANTA FE BLVD
Second Line	:	SUITE 101
City	:	AVONDALE
State	:	AZ
Zip	:	85392-2002
Country	:	US
Telephone Number	:	623-935-7788
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	AARON DEGROOT
Credential	:
Telephone Number	:	623-935-7788

Provider Enumeration Date	:	02/07/2012
Last Update Date	:	02/07/2012

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