Provider Demographics
NPI:1003023839
Name:FRIEDER, GLENN BARRY (DC)
Entity Type:Individual
Prefix:DR
First Name:GLENN
Middle Name:BARRY
Last Name:FRIEDER
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 N ACACIA AVE
Mailing Address - Street 2:#111
Mailing Address - City:SOLANA BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92075-1165
Mailing Address - Country:US
Mailing Address - Phone:858-794-0300
Mailing Address - Fax:858-794-2722
Practice Address - Street 1:125 N ACACIA AVE
Practice Address - Street 2:#111
Practice Address - City:SOLANA BEACH
Practice Address - State:CA
Practice Address - Zip Code:92075-1165
Practice Address - Country:US
Practice Address - Phone:858-794-0300
Practice Address - Fax:858-794-2722
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-17
Last Update Date:2010-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC13313111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAT04968Medicare UPIN