Provider Demographics
NPI:1386865319
Name:PETTERSEN, GLEN C (DC)
Entity Type:Individual
Prefix:DR
First Name:GLEN
Middle Name:C
Last Name:PETTERSEN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2451 N MCMULLEN BOOTH RD STE 312B
Mailing Address - Street 2:
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33759-1342
Mailing Address - Country:US
Mailing Address - Phone:727-260-4366
Mailing Address - Fax:727-222-3838
Practice Address - Street 1:2451 N MCMULLEN BOOTH RD STE 312B
Practice Address - Street 2:
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33759-1342
Practice Address - Country:US
Practice Address - Phone:727-260-4366
Practice Address - Fax:727-222-3838
Is Sole Proprietor?:No
Enumeration Date:2007-05-01
Last Update Date:2021-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH8923111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor