Provider Demographics
NPI:1114091022
Name:RASMUSSEN, GLEN GILBERT (DC)
Entity Type:Individual
Prefix:DR
First Name:GLEN
Middle Name:GILBERT
Last Name:RASMUSSEN
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 1:11 BERKSHIRE LOOP
Mailing Address - Street 2:
Mailing Address - City:PAWLEYS ISLAND
Mailing Address - State:SC
Mailing Address - Zip Code:29585-6349
Mailing Address - Country:US
Mailing Address - Phone:843-235-1034
Mailing Address - Fax:
Practice Address - Street 1:1943 GLENNS BAY RD
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29575-4833
Practice Address - Country:US
Practice Address - Phone:843-650-1162
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-20
Last Update Date:2008-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3082111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCAA16650281Medicare PIN