Healthcare Provider Details

I. General information

NPI: 1760569057
Provider Name (Legal Business Name): DANIEL G. JIVIDEN D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: DANIEL G. JIVIDEN D.C.

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

66 NICHOLS ST
SPENCERPORT NY
14559-2192
US

IV. Provider business mailing address

PO BOX 412
SPENCERPORT NY
14559-0412
US

V. Phone/Fax

Practice location:
  • Phone: 585-352-3254
  • Fax: 585-349-7194
Mailing address:
  • Phone: 585-352-3254
  • Fax: 585-349-7194

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberX007764-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: