Provider Demographics
NPI:1225205636
Name:DEGRAAF, GLENN C (DC)
Entity Type:Individual
Prefix:DR
First Name:GLENN
Middle Name:C
Last Name:DEGRAAF
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 1:244 EDGEFIELD RD
Mailing Address - Street 2:
Mailing Address - City:NORTH AUGUSTA
Mailing Address - State:SC
Mailing Address - Zip Code:29841-2407
Mailing Address - Country:US
Mailing Address - Phone:803-279-3360
Mailing Address - Fax:803-279-9440
Practice Address - Street 1:244 EDGEFIELD RD
Practice Address - Street 2:
Practice Address - City:NORTH AUGUSTA
Practice Address - State:SC
Practice Address - Zip Code:29841-2407
Practice Address - Country:US
Practice Address - Phone:803-279-3360
Practice Address - Fax:803-279-9440
Is Sole Proprietor?:No
Enumeration Date:2008-05-14
Last Update Date:2008-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1358111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC4215985OtherAETNA
SCGCH119Medicaid
SC4215985OtherAETNA
SCT837543911Medicare PIN