Provider Demographics
NPI:1477878841
Name:GLENN, JOE (DC)
Entity Type:Individual
Prefix:DR
First Name:JOE
Middle Name:
Last Name:GLENN
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 1:408 S BROADWAY AVE
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75702-8101
Mailing Address - Country:US
Mailing Address - Phone:903-595-5190
Mailing Address - Fax:903-595-5190
Practice Address - Street 1:408 S BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75702-8101
Practice Address - Country:US
Practice Address - Phone:903-595-5190
Practice Address - Fax:903-595-5190
Is Sole Proprietor?:No
Enumeration Date:2010-03-29
Last Update Date:2010-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX11385111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor