Provider Demographics
NPI:1336703537
Name:BELL, GLEN (CCP)
Entity Type:Individual
Prefix:
First Name:GLEN
Middle Name:
Last Name:BELL
Suffix:
Gender:M
Credentials:CCP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24915 BIRDIES GRN
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78260-4841
Mailing Address - Country:US
Mailing Address - Phone:817-875-6990
Mailing Address - Fax:
Practice Address - Street 1:3463 MAGIC DR
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229-2973
Practice Address - Country:US
Practice Address - Phone:210-614-8101
Practice Address - Fax:210-614-8102
Is Sole Proprietor?:No
Enumeration Date:2019-04-24
Last Update Date:2019-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXFPF00000471242T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes242T00000XTechnologists, Technicians & Other Technical Service ProvidersPerfusionist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX08501434OtherDRIVER LICENSE