Provider Demographics
NPI:1376513051
Name:COLLAZO, GLENN NICHOLAS (DC)
Entity Type:Individual
Prefix:DR
First Name:GLENN
Middle Name:NICHOLAS
Last Name:COLLAZO
Suffix:
Gender:M
Credentials:DC
Other - Prefix:DR
Other - First Name:GLENN
Other - Middle Name:NICHOLAS
Other - Last Name:COLLAZO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DC
Mailing Address - Street 1:12 WORTENDYKE RD
Mailing Address - Street 2:
Mailing Address - City:PARK RIDGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07656-2046
Mailing Address - Country:US
Mailing Address - Phone:201-750-7246
Mailing Address - Fax:201-497-6614
Practice Address - Street 1:12 WORTENDYKE RD
Practice Address - Street 2:
Practice Address - City:PARK RIDGE
Practice Address - State:NJ
Practice Address - Zip Code:07656-2046
Practice Address - Country:US
Practice Address - Phone:201-750-7246
Practice Address - Fax:201-497-6614
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-25
Last Update Date:2011-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ38MC00430900111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ029442Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER
NJ20-0186486Medicare UPIN