Provider Demographics
NPI:1235271016
Name:WALDNER, GLEN E (CPO LPO)
Entity Type:Individual
Prefix:
First Name:GLEN
Middle Name:E
Last Name:WALDNER
Suffix:
Gender:M
Credentials:CPO LPO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:126 SYCAMORE DRIVE
Mailing Address - Street 2:
Mailing Address - City:PRATTVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:36066
Mailing Address - Country:US
Mailing Address - Phone:334-730-4835
Mailing Address - Fax:
Practice Address - Street 1:2865 ZELDA ROAD
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36106
Practice Address - Country:US
Practice Address - Phone:334-395-8118
Practice Address - Fax:334-395-8119
Is Sole Proprietor?:No
Enumeration Date:2007-02-12
Last Update Date:2008-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPOR151174400000X
AL183174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist