Provider Demographics
NPI:1134287485
Name:SCHAEFER, GLEN C (DC)
Entity Type:Individual
Prefix:MR
First Name:GLEN
Middle Name:C
Last Name:SCHAEFER
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 1:1822 W KETTLEMAN LANE
Mailing Address - Street 2:SUITE 5
Mailing Address - City:LODI
Mailing Address - State:CA
Mailing Address - Zip Code:95242-4218
Mailing Address - Country:US
Mailing Address - Phone:209-368-1023
Mailing Address - Fax:209-368-8442
Practice Address - Street 1:1822 W KETTLEMAN LANE
Practice Address - Street 2:SUITE 5
Practice Address - City:LODI
Practice Address - State:CA
Practice Address - Zip Code:95242-4218
Practice Address - Country:US
Practice Address - Phone:209-368-1023
Practice Address - Fax:209-368-8442
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-05
Last Update Date:2011-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA15028111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC0150280Medicare ID - Type Unspecified