Provider Demographics
NPI:1306221106
Name:COURTNEY GLENN DPM LLC
Entity Type:Organization
Organization Name:COURTNEY GLENN DPM LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:COURTNEY
Authorized Official - Middle Name:
Authorized Official - Last Name:GLENN
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:814-758-8425
Mailing Address - Street 1:1515 RIVER PL STE 370
Mailing Address - Street 2:
Mailing Address - City:BRASELTON
Mailing Address - State:GA
Mailing Address - Zip Code:30517-5605
Mailing Address - Country:US
Mailing Address - Phone:770-648-5040
Mailing Address - Fax:706-780-5366
Practice Address - Street 1:1515 RIVER PL STE 370
Practice Address - Street 2:
Practice Address - City:BRASELTON
Practice Address - State:GA
Practice Address - Zip Code:30517-5605
Practice Address - Country:US
Practice Address - Phone:770-648-5040
Practice Address - Fax:706-780-5366
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-22
Last Update Date:2022-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPOD001277261QP1100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP1100XAmbulatory Health Care FacilitiesClinic/CenterPodiatric
Provider Identifiers
StateIdentifier IDID TypeIssuer
1831454750OtherPERSONAL NPI NUMBER