Provider Demographics
NPI:1417298910
Name:GARCIA, GLEN MICHAEL
Entity Type:Individual
Prefix:MR
First Name:GLEN
Middle Name:MICHAEL
Last Name:GARCIA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:508 E 10TH ST
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82007-1524
Mailing Address - Country:US
Mailing Address - Phone:307-286-5410
Mailing Address - Fax:
Practice Address - Street 1:118 EVELYN ST
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82007-1029
Practice Address - Country:US
Practice Address - Phone:307-638-9515
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-07
Last Update Date:2013-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator