Provider Demographics
NPI:1417009192
Name:WIERSMA, GLENN ALBERT (DC)
Entity Type:Individual
Prefix:
First Name:GLENN
Middle Name:ALBERT
Last Name:WIERSMA
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:GLENN
Other - Middle Name:ALBERT
Other - Last Name:WIERSMA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:CHIROPRACTOR
Mailing Address - Street 1:3800 PIEDMONT AVE
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94611-5354
Mailing Address - Country:US
Mailing Address - Phone:510-597-0134
Mailing Address - Fax:510-597-0134
Practice Address - Street 1:3800 PIEDMONT AVENUE
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94611-5354
Practice Address - Country:US
Practice Address - Phone:510-597-0134
Practice Address - Fax:510-597-0134
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACA29380111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor