Provider Demographics
NPI:1407954092
Name:AMY C GLASER DC PC
Entity Type:Organization
Organization Name:AMY C GLASER DC PC
Other - Org Name:WALTON CS V PC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:AMY
Authorized Official - Middle Name:C
Authorized Official - Last Name:GLASER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:636-947-9111
Mailing Address - Street 1:PO BOX 735
Mailing Address - Street 2:
Mailing Address - City:FENTON
Mailing Address - State:MO
Mailing Address - Zip Code:63026-0735
Mailing Address - Country:US
Mailing Address - Phone:636-947-9111
Mailing Address - Fax:
Practice Address - Street 1:500 W UNION AVE
Practice Address - Street 2:
Practice Address - City:LITCHFIELD
Practice Address - State:IL
Practice Address - Zip Code:62056-1937
Practice Address - Country:US
Practice Address - Phone:636-947-9111
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2013-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038-010376111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL212156Medicare ID - Type UnspecifiedGROUP NUMBER