Provider Demographics
NPI:1083781868
Name:GLOVER, TARA STATEN (DC)
Entity Type:Individual
Prefix:DR
First Name:TARA
Middle Name:STATEN
Last Name:GLOVER
Suffix:
Gender:F
Credentials:DC
Other - Prefix:DR
Other - First Name:TARA
Other - Middle Name:MARCELLA
Other - Last Name:STATEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DC
Mailing Address - Street 1:224 WESTINGHOUSE BLVD STE 606
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28273-6248
Mailing Address - Country:US
Mailing Address - Phone:704-369-5700
Mailing Address - Fax:704-817-3070
Practice Address - Street 1:224 WESTINGHOUSE BLVD STE 606
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28273-6248
Practice Address - Country:US
Practice Address - Phone:704-369-5700
Practice Address - Fax:704-817-3070
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-29
Last Update Date:2024-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC3133111N00000X, 111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCCH 2905Medicaid