Provider Demographics
NPI:1245390061
Name:AZZARI, GLENN KEITH (DC)
Entity Type:Individual
Prefix:DR
First Name:GLENN
Middle Name:KEITH
Last Name:AZZARI
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 1:12015 N SAGUARO BLVD
Mailing Address - Street 2:SUITE 103
Mailing Address - City:FOUNTAIN HILLS
Mailing Address - State:AZ
Mailing Address - Zip Code:85268-4680
Mailing Address - Country:US
Mailing Address - Phone:480-836-0800
Mailing Address - Fax:480-816-8886
Practice Address - Street 1:12015 N SAGUARO BLVD
Practice Address - Street 2:SUITE 103
Practice Address - City:FOUNTAIN HILLS
Practice Address - State:AZ
Practice Address - Zip Code:85268-4680
Practice Address - Country:US
Practice Address - Phone:480-836-0800
Practice Address - Fax:480-816-8886
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-11
Last Update Date:2007-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ5517111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZAZ0242170OtherBCBS
AZZ24347Medicare ID - Type Unspecified