Provider Demographics
NPI:1770139693
Name:THIVIERGE, MADDISON (ND)
Entity type:Individual
Prefix:
First Name:MADDISON
Middle Name:
Last Name:THIVIERGE
Suffix:
Gender:F
Credentials:ND
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5271 N AMHERST ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97203-5261
Mailing Address - Country:US
Mailing Address - Phone:541-631-1607
Mailing Address - Fax:
Practice Address - Street 1:1202 BRISTOL ST FL 2
Practice Address - Street 2:
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92626-8605
Practice Address - Country:US
Practice Address - Phone:714-424-9001
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-15
Last Update Date:2019-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175F00000XOther Service ProvidersNaturopath