Provider Demographics
NPI:1760569057
Name:JIVIDEN, DANIEL G (DC)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:G
Last Name:JIVIDEN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:DANIEL
Other - Middle Name:G
Other - Last Name:JIVIDEN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DC
Mailing Address - Street 1:PO BOX 412
Mailing Address - Street 2:
Mailing Address - City:SPENCERPORT
Mailing Address - State:NY
Mailing Address - Zip Code:14559-0412
Mailing Address - Country:US
Mailing Address - Phone:585-352-3254
Mailing Address - Fax:585-349-7194
Practice Address - Street 1:66 NICHOLS ST
Practice Address - Street 2:
Practice Address - City:SPENCERPORT
Practice Address - State:NY
Practice Address - Zip Code:14559-2192
Practice Address - Country:US
Practice Address - Phone:585-352-3254
Practice Address - Fax:585-349-7194
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX007764-1111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY11771BMedicare ID - Type Unspecified