Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NX0800X | Chiropractor Orthopedic Specialist | DC16390 | CA |
NPI | 1801811005 |
---|---|
Provider Name | Dr. Kevin Scott Glenn |
First Address | Diamond Bar, CA 91765-2054 |
Second Address | Diamond Bar, CA 91765-2054 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 12/07/2006 |
Last Update Date | 09/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
T18319 | (02) | CA |