Provider Demographics
NPI:1467576066
Name:EASTON, GLENN (CO,BOCPO,LPO)
Entity Type:Individual
Prefix:MR
First Name:GLENN
Middle Name:
Last Name:EASTON
Suffix:
Gender:M
Credentials:CO,BOCPO,LPO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:141 SILOAM RD
Mailing Address - Street 2:
Mailing Address - City:FREEHOLD
Mailing Address - State:NJ
Mailing Address - Zip Code:07728-8608
Mailing Address - Country:US
Mailing Address - Phone:646-262-1845
Mailing Address - Fax:
Practice Address - Street 1:141 SILOAM RD
Practice Address - Street 2:
Practice Address - City:FREEHOLD
Practice Address - State:NJ
Practice Address - Zip Code:07728-8608
Practice Address - Country:US
Practice Address - Phone:800-718-7856
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-19
Last Update Date:2012-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ45PO000139001744P3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case Management