Provider Demographics
NPI:1235286089
Name:GRUBY, GLENN K (LAC)
Entity Type:Individual
Prefix:
First Name:GLENN
Middle Name:K
Last Name:GRUBY
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1050 KINGS HWY N
Mailing Address - Street 2:SUITE 203
Mailing Address - City:CHERRY HILL
Mailing Address - State:NJ
Mailing Address - Zip Code:08034-1909
Mailing Address - Country:US
Mailing Address - Phone:856-321-9301
Mailing Address - Fax:
Practice Address - Street 1:1050 KINGS HWY N
Practice Address - Street 2:SUITE 203
Practice Address - City:CHERRY HILL
Practice Address - State:NJ
Practice Address - Zip Code:08034-1909
Practice Address - Country:US
Practice Address - Phone:856-321-9301
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-04
Last Update Date:2016-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC9290171100000X
NJ25MZ00035000171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist