Provider Demographics
NPI:1134126287
Name:CZULADA, GLENN (DC)
Entity Type:Individual
Prefix:DR
First Name:GLENN
Middle Name:
Last Name:CZULADA
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:RR 9 BOX 9342C
Mailing Address - Street 2:
Mailing Address - City:MOSCOW
Mailing Address - State:PA
Mailing Address - Zip Code:18444-9410
Mailing Address - Country:US
Mailing Address - Phone:570-842-8804
Mailing Address - Fax:
Practice Address - Street 1:1201 WHEELER AVE
Practice Address - Street 2:
Practice Address - City:DUNMORE
Practice Address - State:PA
Practice Address - Zip Code:18510-1236
Practice Address - Country:US
Practice Address - Phone:570-343-0400
Practice Address - Fax:570-342-5877
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-05
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADL002728L111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0009658730002Medicaid
PAT 28401Medicare UPIN
PA089674Medicare ID - Type UnspecifiedPROVIDER NUMBER