Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111N00000X | Chiropractor | 0104000930 | VA |
NPI | 1992783583 |
---|---|
Provider Name | Dr. Glenn M Stark |
First Address | Martinsville, VA 24112-2014 |
Second Address | Martinsville, VA 24112-2014 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 04/01/2006 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
U51618 | (02) | VA |