Provider Demographics
NPI:1063776961
Name:SHIVERS, DARCI LEE (QMHA)
Entity type:Individual
Prefix:
First Name:DARCI
Middle Name:LEE
Last Name:SHIVERS
Suffix:
Gender:F
Credentials:QMHA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:272 MEDICAL LOOP
Mailing Address - Street 2:SUITE E
Mailing Address - City:ROSEBURG
Mailing Address - State:OR
Mailing Address - Zip Code:97471
Mailing Address - Country:US
Mailing Address - Phone:541-440-3532
Mailing Address - Fax:541-440-3554
Practice Address - Street 1:272 MEDICAL LOOP
Practice Address - Street 2:SUITE C
Practice Address - City:ROSEBURG
Practice Address - State:OR
Practice Address - Zip Code:97471
Practice Address - Country:US
Practice Address - Phone:541-440-3532
Practice Address - Fax:541-440-3554
Is Sole Proprietor?:No
Enumeration Date:2012-06-26
Last Update Date:2015-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500665854Medicaid