Provider Demographics
NPI:1336306075
Name:EARL, GLENN L (PHD, OMD)
Entity Type:Individual
Prefix:DR
First Name:GLENN
Middle Name:L
Last Name:EARL
Suffix:
Gender:M
Credentials:PHD, OMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:358 S 700 E
Mailing Address - Street 2:SUITE B-510
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84102-2161
Mailing Address - Country:US
Mailing Address - Phone:801-355-8226
Mailing Address - Fax:
Practice Address - Street 1:34 S 500 E
Practice Address - Street 2:SUITE 103
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84102-1023
Practice Address - Country:US
Practice Address - Phone:801-355-8226
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-20
Last Update Date:2008-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT100240-1201171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist