Provider Demographics
NPI:1164430518
Name:SPIVA, SUSAN L (RD, CDE)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:L
Last Name:SPIVA
Suffix:
Gender:F
Credentials:RD, CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:825 E MAIN ST STE C
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-7171
Mailing Address - Country:US
Mailing Address - Phone:541-245-0713
Mailing Address - Fax:
Practice Address - Street 1:825 E MAIN ST STE C
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-7171
Practice Address - Country:US
Practice Address - Phone:541-245-0713
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-03
Last Update Date:2007-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR366133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR135261Medicare PIN