Provider Demographics
NPI:1265493761
Name:CLOUD, GLENN S (DC QME)
Entity Type:Individual
Prefix:DR
First Name:GLENN
Middle Name:S
Last Name:CLOUD
Suffix:
Gender:M
Credentials:DC QME
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:417 W LA HABRA BLVD
Mailing Address - Street 2:
Mailing Address - City:LA HABRA
Mailing Address - State:CA
Mailing Address - Zip Code:90631
Mailing Address - Country:US
Mailing Address - Phone:562-691-2225
Mailing Address - Fax:562-691-9725
Practice Address - Street 1:417 W LA HABRA BLVD
Practice Address - Street 2:
Practice Address - City:LA HABRA
Practice Address - State:CA
Practice Address - Zip Code:90631
Practice Address - Country:US
Practice Address - Phone:562-691-2225
Practice Address - Fax:562-691-9725
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-01
Last Update Date:2007-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA14340111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAT17763Medicare UPIN
CAWDC14340AMedicare PIN