Provider Demographics
NPI:1083694210
Name:GROOTHUIS, GLEN LEROY (DC)
Entity Type:Individual
Prefix:DR
First Name:GLEN
Middle Name:LEROY
Last Name:GROOTHUIS
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 1:107 ELDORA RD.
Mailing Address - Street 2:
Mailing Address - City:HUDSON
Mailing Address - State:IA
Mailing Address - Zip Code:50643-0366
Mailing Address - Country:US
Mailing Address - Phone:319-988-3336
Mailing Address - Fax:319-988-3196
Practice Address - Street 1:107 ELDORA RD.
Practice Address - Street 2:
Practice Address - City:HUDSON
Practice Address - State:IA
Practice Address - Zip Code:50643-0366
Practice Address - Country:US
Practice Address - Phone:319-988-3336
Practice Address - Fax:319-988-3196
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA03028111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0016899Medicaid
IAT00199Medicare UPIN
IA01689Medicare ID - Type Unspecified