Provider Demographics
NPI:1467498204
Name:BUB, GLEN (DC)
Entity Type:Individual
Prefix:
First Name:GLEN
Middle Name:
Last Name:BUB
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 1:1851 SCHOETTLER RD
Mailing Address - Street 2:
Mailing Address - City:CHESTERFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:63017-5529
Mailing Address - Country:US
Mailing Address - Phone:636-227-2100
Mailing Address - Fax:
Practice Address - Street 1:1851 SCHOETTLER RD
Practice Address - Street 2:
Practice Address - City:CHESTERFIELD
Practice Address - State:MO
Practice Address - Zip Code:63017-5529
Practice Address - Country:US
Practice Address - Phone:636-227-2100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-21
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO004853111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOT37592Medicare UPIN