Provider Demographics
NPI:1548571029
Name:MCIVER, IMOGENE (RD)
Entity Type:Individual
Prefix:
First Name:IMOGENE
Middle Name:
Last Name:MCIVER
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1301 S CRISMON RD
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85209-3767
Mailing Address - Country:US
Mailing Address - Phone:480-358-6353
Mailing Address - Fax:
Practice Address - Street 1:1301 S CRISMON RD
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85209-3767
Practice Address - Country:US
Practice Address - Phone:480-358-6353
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-29
Last Update Date:2010-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ913524133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered