Provider Demographics
NPI:1124327564
Name:RANDAL JOSEPH THIVIERGE
Entity type:Organization
Organization Name:RANDAL JOSEPH THIVIERGE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OPERATIONS MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:JODY
Authorized Official - Middle Name:L
Authorized Official - Last Name:LAVOIE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:207-236-3100
Mailing Address - Street 1:625 ROCKLAND ST
Mailing Address - Street 2:
Mailing Address - City:ROCKPORT
Mailing Address - State:ME
Mailing Address - Zip Code:04856-5320
Mailing Address - Country:US
Mailing Address - Phone:207-236-3100
Mailing Address - Fax:207-236-8380
Practice Address - Street 1:625 ROCKLAND ST
Practice Address - Street 2:
Practice Address - City:ROCKPORT
Practice Address - State:ME
Practice Address - Zip Code:04856-5320
Practice Address - Country:US
Practice Address - Phone:207-236-3100
Practice Address - Fax:207-236-8380
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-24
Last Update Date:2011-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME3037332BC3200X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized EquipmentGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME6529680001Medicare NSC