Provider Demographics
NPI:1962597369
Name:THIBODEAU, PAIGE (DC)
Entity type:Individual
Prefix:
First Name:PAIGE
Middle Name:
Last Name:THIBODEAU
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4736 SCOTTS VALLEY DR
Mailing Address - Street 2:SUITE B
Mailing Address - City:SCOTTS VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:95066-4226
Mailing Address - Country:US
Mailing Address - Phone:831-438-0308
Mailing Address - Fax:831-438-0437
Practice Address - Street 1:4736 SCOTTS VALLEY DR
Practice Address - Street 2:SUITE B
Practice Address - City:SCOTTS VALLEY
Practice Address - State:CA
Practice Address - Zip Code:95066-4226
Practice Address - Country:US
Practice Address - Phone:831-438-0308
Practice Address - Fax:831-438-0437
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC0100020111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAT03794Medicare UPIN